The Claim Game
Starting a new claim with the VA?
There are probably a hundred questions running through your mind right now: When am I going to hear something? How do I know VA is doing the right thing with my claim? What are all these letters?! What are the rules?!
Welcome to the Claim Game! Admittedly, the rules are not transparent or even easily accessible, but this blog series will help to answer some of those questions. If you’re still feeling a bit lost in the woods – we’re here to help!
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Overview of the Claim Process
Once a Veteran or claimant files a claim with the VA, the VA must process that claim and afford the claimant any assistance that might be needed to fully develop the claim. This “Duty to Assist” is a unique hallmark of the VA claims systems. Codified in law in 2000 under the Veterans Claims Assistance Act, there are particular duties the VA owes to the claimant once a claim has been received. These duties include:
- A duty to notify claimants of evidence required to substantiate claim;
- A duty to obtain private treatment records (when identified);
- A duty to obtain federally held records, including your active duty service treatment records and any treatment records at VA Medical Centers.
VA Process
Thus – the first thing that VA is going to do when it receives a claim is start sending letters to work on these items. You’ll get several letters in the first few months of your claim, but VA’s duty to assist doesn’t just end at sending letters and gathering outstanding records, the most important step that will happen during the claims process is the VA exam.
VA is required to order an exam when the medical evidence of record is insufficient to grant a benefit. In a service connection claim, this could be that “nexus” requirement. In an increase rating claim, the VA may need particular medical evidence to appropriately rate the claim, or assess whether a condition may prevent a veteran from working. Exams are part of the process and it is generally not recommended to skip an examination unless there is a plan to submit the missing medical evidence in lieu of VA’s own examination. VA can deny a claim simply for a missed VA examination.
Once all necessary exams are completed, and VA has obtained all necessary and outstanding records (or exhausted all attempts to obtain those records), it then turns to the actual decision making. However, sometimes after the exams are ordered, VA may continue to develop the claim. A veteran may get additional letters, or even get ordered to a repeat examination.
Additional development that occurs after VA examinations is not a precursor to a denial. Instead, this development may be beneficial to the claimant, and is usually in response to something entering the record that triggers VA to dig deeper. For example, the examinations might document that a veteran is unable to work or had to leave work due to a service connected disability and is now on Social Security Disability. This evidence may raise the issue of entitlement to Individual Unemployability, and VA would then have a duty to obtain records from Social Security Administration to confirm the veteran’s disability status.
Example filing a claim
A veteran files a new claim for service connection for tinnitus and migraine headaches. VA may develop both of these claims on a “direct” service connection basis (whether the issues are directly related to the veteran’s active duty service). However, after the examinations, it may come to light that the veteran’s migraines are triggered due to the tinnitus. Thus, VA may request an updated examination or medical opinion to confirm this relationship as a basis for a future award of service connection.
Sometimes VA’s intentions in its additional development is not always so clear to the Veteran – but your accredited representative will be able to determine the cause for VA’s development. Ultimately, these are steps that every claim must go through to be successful.
And speaking of a successful resolution, after the appropriate development, and completion of necessary exams, VA will then issue its final decision. The “Rating Decision” is accompanied by a notification letter and contains VA’s decision on each claimed issues, as well as some rationale for its decision and the list of evidence that it considered. If VA denies a claim, they must include any “favorable findings” that it made. These favorable findings could be things such as VA acknowledging the veteran’s diagnosis, or acknowledging the in-service event in a claim for service connection, and may help to provide a roadmap should you need to challenge VA’s denial in the future. Keep in mind that should you wish to challenge a Rating Decision by the VA, you will retain your initial effective date if you challenge that decision within one year from the date of VA’s decision.
The claims process takes patience and preparedness and should always be navigated with the aid and expertise of an accredited representative. Need help with you claim, or had your claim denied? Let us help you!