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Disability Compensation

Disability Compensation. Texas Veterans Commission Fall Conference 2009. Overview. Comp. = Key 6 Lessons Eligibility Criteria Application Procedures Claims Processing Flow Ratings Dependency Requirements Payments. Eligibility Criteria. Disability Injured in service

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Disability Compensation

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  1. Disability Compensation Texas Veterans Commission Fall Conference 2009

  2. Overview • Comp. = Key • 6 Lessons • Eligibility Criteria • Application Procedures • Claims Processing Flow • Ratings • Dependency Requirements • Payments

  3. Eligibility Criteria • Disability • Injured in service • Aggravation of an injury in service • Ill in service & continuing problems • Condition developed in service • Presumptive condition within 1 year of discharge • Presumptive condition from exposure

  4. Eligibility Criteria (Cont.) • Types of Conditions • Acute Condition • Chronic condition • Acute & Chronic

  5. Eligibility Criteria (Cont.) • Service Requirements • Active Duty • Disease or Injury during full-time duty in Reserves or National Guard • Injury during inactive duty for training in Reserves or National Guard • No Dishonorable discharge • Not incurred as a result of willful misconduct

  6. Eligibility Criteria (Cont.) • Service Requirements (Cont.) • No Length of service requirement • No wartime service requirement

  7. Eligibility Criteria (Cont.) • Establishing Service Connection • Direct Incurrence • Aggravation • Presumption • As a secondary condition • Provisions of 38 U.S.C. 1151

  8. Application Procedures • VA Form 21-526 (Review Blank Form Provided) • Application for Compensation and/or Pension • 7 Pages of General Instructions • 4 Parts (A, B, C, & D) • Each part has sections numbered I, II, III, IV etc. • Each page has the Part & Page number at lower right hand side of the page.

  9. Application Procedures (Cont.) Documents sent with Application • Discharge papers • DD-214 (copy 4) • Veterans service before 1947 • Army veterans WDAGO 53-98 • Navy personnel NAVPERS Form 553 • Ltr from National archives

  10. Application Procedures (Cont.) Required Info on Separation Document • Branch of Service • Dates of Service • Character of Separation

  11. Application Procedures (Cont.) Documents sent with Application (Cont.) • VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative • Specific Power of Attorney • National Organizations 38 (Membership does not mean POA) • State Organization is TVC

  12. Application Procedures (Cont.) Documents sent with Application (Cont.) • VA Form 21-4142, Authorization and Consent to Release Information to the Dept. of VA • Authorizes VA to obtain private medical records • One per doctor, hospital or clinic • Not required for VA facilities

  13. CLAIMS PROCESSING Claims Processing Improvement (CPI) Teams (6) • Triage Team • Pre-Determination Team • Rating Team • Post-Determination Team • Appeals Team • Public Contact Team

  14. CLAIMS PROCESSING(Cont.) • Triage team • Receives Mail • Processes little development claims • Routes other claims • Pre-determination • Appeals • POW • Terminal Ill / Over 65

  15. CLAIMS PROCESSING (Cont.) • Pre-Determination Team (Pre-D) • “Develops” claim • Request SMR’s / STR’s • Request Service Records • Request private medical records • Request Compensation & Pension (C&P) Exam

  16. CLAIMS PROCESSING (Cont.) • Rating Team • Renders decisions (Rating reference is CFR 38 Part 4)

  17. CLAIMS PROCESSING (Cont.) • Post-Determination Team • Prepares, inputs & sends notification letters

  18. CLAIMS PROCESSING (Cont.) • Appeals Team Appeal • Long Process! • Other options • Reopened Claim • Not possible Claims

  19. CLAIMS PROCESSING (Cont.) Appeals (Cont.) • Notice of Disagreement (NOD) • VA Form 21-4138 (Statement in Support of Claim) • Include: • “Notice of Disagreement with decision of DD-MM-YEAR” • List each issue • If available submit evidence • Elect DRO or Traditional Appeal Process

  20. CLAIMS PROCESSING (Cont.) DRO = Decision Review Officer • One Person • Reviews Entire Claim • Authority to Grant Benefits • If DRO continues denial, Sends SOC (Statement of Case) & Form 9 • Form 9 starts Traditional Appeal Process • Almost ALWAYS better to elect DRO

  21. CLAIMS PROCESSING (Cont.) Traditional Appeal (Form 9) • Make a choice of a hearing or not • List Issue(s) Appealing • Make a Statement of Argument

  22. CLAIMS PROCESSING (Cont.) Appeal’s Time Limits • NOD (Notice of Disagreement) • 1 Year from date of Decision Letter • VA Form 9 • 60 Days from Date of SOC (Statement of Case) • 1 Year from date of Decision Letter Whichever is Later

  23. CLAIMS PROCESSING (Cont.) • Public Contact Team • Walk-In Inquiries • Mail Inquiries • Congressional Correspondences • Outreach • Fiduciary Issues

  24. RATINGS Facts • Congress Establishes Amounts • Percentages Increase with Severity of Disability • May be Rated at 0% • Percentage is Impairment in Earning Capacity • May have several ratings but only one combined rating

  25. RATINGS Combined Ratings (or VA Math) 30% + 20% is 40% NOT 50% Explanation: A Single rating is what it is. The second and following rating are the percentage of what is left over after the first or previous ratings.

  26. RATINGS Combined Ratings (Cont.) 30% + 20% = 40% 100% - 30% (Largest Rating) = 70% 20% (Next largest Rating) of 70% (What was left over) = 14% Therefore 30% + 14% = 44% That Rounds to 40%

  27. RATINGS Combined Ratings Table

  28. RATINGS Read table in Matrix format 1st (Largest Number) on left, 2nd Next largest Number on Top

  29. RATINGS Intersecting Number is Rating Ends in 4 or below Round Down Ends in 5 or Above Round Up Therefore 30% + 20% = 40%

  30. RATINGS Combined Ratings Table Practical Application • 60% + 10% = 60% • 50% + 30% + 20% = 70% • 80% + 40% + 30% = 90%

  31. RATINGS SMC (Special Monthly Compensation) • Special Allowance for Sever Disabilities • Usually Loss or Loss of Use of a body part • Also for Housebound or in need of A&A (Aid and Attendance) • 8 Designators (K, L, M, N, O, Q, R, & S) • Combination & Intermediate Ratings make 60 Different Levels

  32. RATINGS I/U (Individual Unemployability) • Rated at Less than 100%, but paid at 100% Rate • SC (Service Connected) disabilities preclude GAINFUL employment

  33. RATINGS Gainful Employment IS = Over the Poverty Threshold for one Person www.census.gov/hhes/www/poverty/threshld/thresh07 IS NOT = • Odd Jobs • Jobs in a “Protected” Environment • Family Business • Sheltered Workshop

  34. RATINGS Temporary Ratings (38 CFR 4.28, 4.29, 4.30) • Paragraph 28 (Prestabilization) Normally for recently separated veterans with unstable disability • Temp. 50% or 100% • Paragraph 29 (Hospitalization) Hospitalized more than 21 Days for SC disability • Temp. 100%

  35. RATINGS • Paragraph 30 (Surgical/Convalescent) • Surgery for SC disability requiring min. 1 month convalescence. • Surgery for SC disability with severe postoperative residuals. • Immobilization by cast of SC disability of at least 1 major joint.

  36. RATINGS Permanently & Totally Disabled (P&T) • Permanent = Reasonably certain to continue throughout lifetime • Totally = impairment render it impossible to follow gainful occupation

  37. RATINGS Reviews & Future Exams • VA will schedule a periodic reevaluation of disabilities likely to improve

  38. RATINGS Reviews & Future Exams (Cont.) • Reexamination are NOT usually scheduled if: • Veteran is over 55 • Disability is static • Disability fm disease is permanent • Combined rating would not change if lowered to lowest level possible • Over 5 years without material improvement

  39. RATINGS Protected Ratings • SC rating 10 years or more cannot be revoked • SC rating 20 years or more cannot be reduced

  40. RATINGS Incompetency Rating • Unable to manage own financial affairs • Considered in every rating with a diagnosis of psychosis • If incompetency is found, VA will appoint a Fiduciary

  41. RATINGS Special Issues, Concern to VA & Congress (7) • Post-Traumatic Disorder (PTSD) • Agent Orange Exposure • Prisoner of War (POW) • Radiation Exposure • AIDS • Asbestos Exposure • Mustard Gas Exposure

  42. RATINGS Review 3 Most Common Special Issues • Post-Traumatic Disorder (PTSD) • Agent Orange • Radiation

  43. RATINGS PTSD • Three Requirements for SC • In-Service Stressor • Current Medical Diagnosis • Relationship (Nexus) between Stressor & Diagnosis

  44. RATINGS Stressor • Threat to one’s life • Threat to one’s Relatives or Friends • Seeing another seriously injured or killed

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