Development Guide for Compensation & Pension Benefits

 March 1995

Department of Veterans Affairs

Compensation and Pension Service

Washington, DC

 

Introduction

The need for this guide developed from the increasing complexity of the development process. Numerous decisions from the Board of Veteransí Appeals and Court of Veterans Appeals along with more medically complex issues and a continually changing body of medical information have resulted in the cumbersome, fragmented, and confusing material currently available. While the information needed to successfully develop claims is present, its use is far too complicated.

The purpose of this guide is to provide a convenient, easy to use reference for the vast majority of development actions for claims under Rating Activity jurisdiction. It is not designed to be all-encompassing. Nor does it replace or supersede information provided in M21-1 or 38 CFR. Rather, it is to be used in conjunction with other reference material.

The goal of the guide is simple; to help ensure that every claim is developed completely, consistently and in a timely manner the first time. Of course, this will not happen every time. Many times new potential evidence becomes available late in the development process. Nothing can be done about those situations. However, this guide will assist in ensuring that all evidence of record is developed fully.

The guide is written with the understanding that the user already has a working knowledge of the development process and basic development requirements. The focus of the guide is on requirements which are more issue oriented and seem to cause confusion in the development process. For instance, development of a radiation claim.

The development process is in constant change. Likewise, the guide is meant to change. Any recommendations for improvement are always appreciated. Please forward any corrections, additions or suggestions to VACO, Compensation & Pension Training (212C).

 

Organization

The guide has been organized into sections on basic development common to all claims and, more specifically, by types of claim. In addition, sections are provided for issue specific development; for instance exposure to herbicide agents, PTSD or asbestos claims. Within each issue specific section are instructions on how to follow development steps specific to that type of claim. Examples of all development screens and suggested letters are also provided which relate to that type of claim.

The information is presented in a brief, outline format. In this manner, the guide can be left in a convenient location and easily followed while doing actual development. Again, the idea is to avoid as much fumbling with manuals and regulations as possible. Citations are provided for more detail and literal interpretation when needed.

This guide is designed to be used in conjunction with the included check sheets for live and death claims.

 

Table of Contents

 

I. General Development Process Section I

 

A. Four Stages of Claims Processing I-1

B. Basic Development Process I-2

C. Check Lists I-6

D. Review of Application/Claim I-7

E. Service Department Development I-8

F. Dependency Development I-17

G. Income Development I-23

 

II. Compensation Section II

 

A. Background II-1

B. Original (EP 010 or 110 series) II-6

C. Re-opened (EP 020 series) II-8

1. Condition previously denied service connection II-8

2. Condition not previously denied (i.e. new condition) II-9

3. Condition already service connected II-9

D. Issue specific claims II-10

1. Exposure to Herbicide Agents (Agent Orange) II-11

2. Asbestos II-14

3. POW II-15

4. Mustard Gas claims II-17

5. Post-Traumatic Stress Disorder II-19

6. Radiation exposure II-24

7. Conditions secondary to drug/alcohol use II-28

8. Smoking II-29

9. 1151 claims II-30

10. Toxic Chemical Exposure Claims II-32

11. HIV/AIDS II-33

12. PGW/Environmental Agents II-34

 

III. Live Pension Section III

A. Original (EP180) III-1

B. Reopened live pensions claims (EP 020) III-2

 

IV. Death Claims Section IV

A. Dependency and Indemnity Compensation (DIC) IV-1

B. Death Pension IV-3

C. Burial Development IV-4

D. Accrued Claims IV-5

 

Table of Contents

 

V. AMIE Quick Reference Guide Section V

Appendix A - Sample Development Letters Appendix A

 

Logical Adjudicative Process

 The application of FACTS to LAW

Where do we find the law? -- * Title 38, United States Code (38 USC)

* Title 38, Code of Federal Regulations (38 CFR)

* Precedent Decisions

 

  THE CLAIMS PROCESS: QUESTIONS FOR EVERY CASE

 

1. What is the issue?

2. Under which laws/regulations can we establish entitlement?

3. What do the facts have to demonstrate to establish entitlement?

4. What evidence do I need to establish the facts?

 

REMINDERS

 

NO SPECIFIC ISSUE = NO CLAIM = NO END PRODUCT

 

INCOMPLETE CLAIM = INFORMAL CLAIM

 

Section I

General Development Process

A. Four Stages of Claims Processing I-1

B. Basic Development Process I-2

C. Checklists I-6

D. Review of Application/Claim I-7

E. Service Department Development I-8

F. Dependency Development I-17

G. Income Development I-23

 

A. The Four Stages of the Claims Process

  

1. Issue(s) to be Decided

 Well-grounded, plausible claim?

If so, we have a duty to assist.

 

2. Development of Facts

What evidence is necessary to resolve the issue(s)?

What evidence is of record?

Develop for all additional evidence necessary to resolve the issue(s).

 

3. Decision - The Application of Facts & Law

a. Facts - Derived from Step 2 and development.

b. Law

(1) Title 38 USC

(2) Regulations - 38 CFR

(3) Precedent Decisions

(4) COVA

(5) GC Opinions

 

4. Notification (38 USC 5104)

 

B. Basic Development Process

Review application for completeness, information identifying the veteran, and claimant's signature.

List all claimed conditions and identify type of claim (original, reopened, increase, pension, etc.).

Verify correctness of End Product.

Determine if potential eligibility based on service exists for benefit claimed.

If pension is claimed, review income and dependency first and determine eligibility.

If service, income, and dependency appear to be complete, continue development.

 

Service Development

Develop for anything needed from military service department (service verification, SMRs, personnel file).

 

 Medical Development

 CLAIM FOR COMPENSATION ONLY:

Less than 1 year since discharge:

Identify and develop any special issues.

Request any medical evidence if indicated.

Request VA exam, if indicated.

  

More than 1 year since discharge:

Request continuity and/or chronicity evidence

Request treatment records from VA or military facilities

Identify and develop any special issues

Request private medical treatment records if indicated

Request VA exam, if indicated

 

 

CLAIM FOR PENSION ONLY:

 Request any records of treatment for the past year:

Private

VA or Military

VR&C

SSA

Request VA exam if indicated

 

DUAL CLAIM: PENSION AND COMPENSATION:

Request any of the evidence indicated as noted above

Some items need not be duplicated

  

CLAIM FOR INCREASE:

Request medical evidence to support claim for increase in severity

Request VAF 21-4142 from veteran

Request private medical evidence, if appropriate

Request VA medical records

Request VA exam, if indicated

 

PREVIOUSLY DENIED CLAIM:

Request specific evidence for consideration

Evidence must be new and material, not duplicate and must bear directly on issue for consideration.

 

SPECIAL MONTHLY COMPENSATION:

Request medical evidence, if indicated

Recent treatment

Aid and Attendance, if indicated

Request VA exam, if indicated

 

SPECIAL MONTHLY PENSION

Request medical evidence

†† Recent treatment

Housebound

†† Aid and Attendance

-- or --

Request supporting statement, if nursing home establishes reason for claim

Develop Medicaid information

Request Expense information

Verify that Nursing home is approved and licensed

 

 COMPETENCY ISSUES:

Request medical evidence and submit for initial rating

Request certified court certificates regarding this issue, if indicated

 

 INDIVIDUAL UNEMPLOYABILITY:

Obtain VA Form 21-8940, Request for Individual Unemployability

Develop for any medical evidence, if needed

Develop employment statements from employers during last year of employment

 

 DEATH CLAIMS:

Obtain Death Certificate

Obtain Autopsy Report, when directed

Obtain Terminal Hospital Report, when directed

Obtain treatment records with initial diagnosis, when directed

 

 COMBINATION CLAIMS:

List all conditions and type of evidence needed to establish a valid claim for consideration of each issue.

Develop each type of evidence needed.

 

Dependency and Income Development

For all types of claims, we recommend Dependency or Income be developed simultaneously with service and medical evidence, if indicated.

 

C. Checklists

 Four development checklists are currently available for use with this Development Guide. There are checklists for burials (VAF 21-0280), compensation (VAF 21-0281), pension (VAF 21-0282), and DIC/death pension/accrued (VAF 21-0283). The checklists are not all-inclusive; however, there is space provided for items not listed.

The items listed are the ones where development is normally required. All items are self explanatory. If there is a question or development of a specific issue, see the development guide for further clarification or necessary manual or CFR citations.

The first column identifies "Issue/Evidence/Action". Preprinted are the most common needs with the last block under each major section shown as "other". The second column, "Of Record", provides a space for the reviewer to insert his or her initials when the evidence is of record. The third set of columns is identified as "Evidence Required". The three sub-columns require entry of what document was requested, when (date), and by whom (initials). The fourth set of columns is to be utilized when the evidence has not been received and "Follow Up" action is due. The date of follow up plus initials are for entry. The final set of columns is titled "Evidence Received". It provides for entry of the date plus initials of the person who has noted the evidence has been received.

The upper portion of the checklist is self-explanatory as to the information for input.

The bottom of the second page of each checklist requires insertion of the suspense period for action, notation of referral to the Rating Activity as well as spacing for additional pertinent notes.

 

 

D. Review of Application/Claim

Completeness: Review the application for completeness. Be sure the application or claim request is signed by the claimant.

 For original claims, the application must contain at a minimum the following:

-claimant's name

-veteran's name

-veteran's social security number or service number

-branch of service

-approximate dates of service

-signature of claimant

 

This is enough to establish a claim, file, and control. If the application is incomplete, it must be copied and the original returned for completion by the claimant.

For reopened claims, any statement indicating the claimant's desire to file a claim may be accepted. Usually these requests are filed by the claimant or her or his representative. An informal claim also establishes a reopened claim if it is based on VA or military hospital medical evidence or congressional inquiries.

Unsigned claims must be returned immediately for signature and no control or end product established. Be sure a date stamp exists on the document and encourage the claimant to resubmit the same document as it may affect the effective date.

 References:

M21-1, Part III, 2.01c,d,e,f

M21-1, Part IV, 6.07

38 CFR 3.113

38 CFR 3.155

 

E. Service Department Development

Service Verification

 Acceptable:

Documents: 38 CFR 3.203; M21-1, Part IV, 10.04b

 

Original copy of DD 214

Carbon copy of DD 214

Copy of DD 214 received from Service Department at time of Discharge (M21-1, Part III, 4.02a(2)

Copy of DD 214 authenticated by Adjudication or Veterans Services Division (not Service Organizations)

 

VADS: M21-1, Part II, 6.05d(19) and (26), 6.05e and 5.20a; Part IV, l0.04c

 

Character of service is HON or UHC

Branch of service code is not ARNG or ANG

Separation reason is SAT

There is a "Y" in the VADS field or VERIFIED field and veteran's RAD is 6-1-68 or later (all persons entering active duty after

11-5-93 will have a "D" in the VADS field until discharged and VADS updated)

 

If veteran retired for length of service (20 years or more) and other evidence is complete, send to Rating Board for action. Request verification of all unverified service via Target 201 and 202 screens and continue to control (M21-1, 10.04d).

 

Fire Related (M21-1, Part III, 4.23) -- On July 12, 1973, a fire at the NPRC in St. Louis destroyed 85 percent of the stored records for Army veterans serving between 1941 and 1960, and 85 percent of Air Force personnel with surnames beginning with the letters I through Z who were discharged prior to 1964 and had no retired or Reserve Status.

 

Every request submitted suspected to be a fire-related case should be on a manually prepared VA Form 21-3101 accompanied by a discharge document.

 If DD 214 is not of record

 If DD 214 is not of record, request veteran to complete DA-13075 or DARP Form 2580 for possible alternate sources (M21-1, Part III, 4.25b). A VA Form 21-3101 to appropriate Service Code should be sent hard copy with either DD 214 or DA-13075 attached. You should make every effort to anticipate possible alternate sources that may be of record on the application. Possible sources of alternate records are:

 

 

Private Records Physicians, Hospitals, etc.

Veteran Centers VA exams

VA hospital and outpatient clinics Military hospitals

Social Security Administration Veteran/Claimant statements

Buddy statements Field exams

Social and Industrial Survey Photographs while in the service

Insurance physical Employment physical

VR&C files Pharmacy prescriptions while in Letters to/from the veteran while in the service

 

Burial Claims:

The evidence which VA relied on to pay compensation or pension during the veteranís lifetime may be used to verify qualifying service for entitlement to non-service connected burial benefits. (M21-1, Part III, 13.05; 38 CFR 3.203(c))

 

Travel Time:

 M21-1, Part III, 2.08c

  

Minimum Active Duty Requirement: (After 9-7-80)

M21-1, Part III, 2.08d

  

Uncharacterized Separations:

38 CFR 3.12(k)

 

 Upgraded Discharges:

 38 CFR 3.12 (e)(f)(g)(h); M21-1, Part IV, 11.01

 

 

POW Dates:

 38 CFR 3.1(y)(2); M21-1, Part III, Chapter 4, Subchapter 8;

M21-1, Part III, 5.16; M21-1, Part II, 6.05(h)(18)

 

Character of Discharge:

 38 CFR 3.12; M21-1, Part IV, 11.01 and 11.02

 

 If discharge is OTH or otherwise questionable:

 

1. Request facts and circumstances using VAF 21-3101 to Service Department

 

2. Request obligated service on same 3101 if service is continuous and more than one period of service is shown. CONDITIONAL DISCHARGE

(38 CFR 3.13; M21-1, Part IV, 11.01i and 11.02g)

 

3. Send veteran Due Process letter allowing 60 days for reply.

(M21-1, Part IV, 11.02).

4. Develop for SMR and all available medical evidence simultaneously. Order a VA exam (if applicable) only if a conditional discharge is indicated (as there is probable entitlement).

5. BUPD should be done after Character of Discharge Decision has been finalized. (M21-1, Part IV, 11.02g(3))

 

Military Benefits

Retired Pay

Carefully examine the veteran's claim, DD 214 and other available separation documents, or BIRLS MSC Screen (which comes from the VADS interface) for any evidence of retired pay. Service retired pay may be verified via 3101 from the appropriate address code per Addendum A of M21-1, Part III, Chapter 4.

 

The veteran may also be requested to furnish verification of the receipt or amount of retired pay; however; the service department MUST verify any conflicting information. (38 CFR 3.750; M21-1, Part IV, 21.01; M21-1, Part III, 2.09; M21-1, Part II, 6.05h).

 

Severance or Readjustment Pay

Carefully examine the veteran's claim, DD 214 and other available separation documents, or BIRLS MSC Screen for any evidence of severance pay. Severance pay may be verified via 3101 from the appropriate address code in Addendum A of M21-1, Part III, Chapter 4. (38 CFR 3.700a(3); M21-1, Part IV, 20.31; M21-1 Part II, 6.05h; M21-1, Part III, 2.09)

 

Voluntary Separation Incentive (VSI) and Special Separation Benefit (SSB)

To facilitate the downsizing of the armed forces, service members have the option to receive payment under one of two incentive programs (VSI or SSB). To qualify for either of these exit bonuses, the service person must have served on active duty for more than six (6) years but fewer than twenty (20) years as of December 5, 1991; served at least five (5) years of continuous active duty immediately before separation; and agree to serve in the Ready Reserve. Service persons approved for separation under SSB or VSI must separate on or before September 30, 1995. SSB provides a lump sum payment while VSI is paid in annual installments.

Identification of veterans receiving SSB or VSI can be found in blocks (18) and (26) of their DD 214s. A VADS record will indicate any SSB payment as LUMP SUM READJUSTMENT PAY on the MSC screen. If a pending issue file is subsequently established, the 401 screen will display 100 percent of that amount in the SEPARATION PAY field. VSI information will not be entered into the VADS record since any offset will be accomplished by DOD.

Questionable receipt of amounts of SSB or VSI may be made to the appropriate service department code via 3101. (38 CFR 3.700; M21-1, Part III, 2.10.1; M21-1, Part IV, 20.31).

 

Requesting Service Medical Records

1. Review VA Form 21-526 and DD Form 214 to check veteran's reserve status (i.e., inactive reserve, active reserve, National Guard, retired, or none).

2. Request service medical records using Target 201, 202 screens. Target requests on VA Form 21-3101-4 for all address codes are printed at the National Personnel Records Center (NPRC) in St. Louis. NPRC uses its indexing system to determine if it has the requested record. If NPRC has the record, it responds to the VA Form 21-3101. If it does not, NPRC forwards the VA Form 21-3101 by mail to the address code entered by the operator at the regional office.

3. The following is a list of frequently used Address Codes. For more detail, consult M21-1, Part III, Chapter 4, Addendum A (Address Codes) and Addendum C (Addresses and phone numbers).

 

 

4. Control and follow-up procedures for SMR requests (and the involvement of station service records specialists) are contained in M21-1, Part III, Chapter 4, Subchapter V. Follow-ups should be promptly made based on circumstances in individual cases, i.e., ever-changing time frames furnished by the various service departments.

  

SMRC - Address Code 375 (M21-1, Part III, 4.01h; M21-1, Part III, Subchapter II

  

SGO - Surgeon General Office records are automatically furnished for 3101 requests after 5-18-90. (M21-1, Part III, 4.22)

  

State Adjutants General (National Guard Headquarters) (M21-1, Part III, Chapter 4, Addendum F)

 

F. Dependency Development

 

Acceptable Verification of Dependency

  

MARITAL RELATIONSHIP

Marriage

The original Marriage Certificate, a copy of the marriage certifcate that has been certified to be a true copy of the original by the custodian of public records, or an uncertified photocopy that is deemed to be genuine and free from alteration by VA, is acceptable evidence.

Alternate evidence may be submitted to document Marriage. (See M21-1, Part III, 6.06).

 

References:

M21-1, Part III, 6.06

M21-1, Part IV, 12.01

38 CFR 3.204, 3.205

C&P Fast Letter 4-92 (9/14/94)

 

 

Common-law Marriage

Some states recognize informal or common law marriages. Once established, it is valid anywhere in all respects and no different from a ceremonial marriage. Requirements vary from state to state but the following three elements must be met in all cases:

 

1. An agreement between the parties to be married.

2. Cohabitation.

3. Holding out to the public as married.

 

References:

M21-1, Part III, 6.08

M21-1, Part IV, 12.03c

38 CFR 3.1 (j)

 

Void and Annulled Marriages

Annulment of marriage can be established by a copy or abstract of the annulment decree. The copy or abstract must bear the original stamp, seal or signature of the custodian of the records, or qualify as an acceptable photocopy under M21-1, Part III, paragraph 1.07a, or is an uncertified photocopy that is deemed to be genuine and free from alteration by VA.

Certain marriages have no legal effect although a marriage ceremony has taken place and the marriage has been registered. If the marriage is determined to be void, fully develop the facts. After development, submit the case to District Counsel for a legal opinion as to whether or not the marriage is void.

 

References:

M21-1, Part III, 6.07g & h

M21-1, Part IV, 12.03

38 CFR 3.207, 3.204

C&P Fast Letter 4-92 (9/14/94)

 

 

Veteran and Spouse - Separated or Estranged

Old Law/Section 306 (See M21-1, Part IV, 16.10)

Improved Pension (See M21-1, Part IV, 16.28)

 

Divorce

Documentary proof of dissolution of prior marriages is not routinely required. A certified statement from the claimant must include:

1. The first and last names of prior marriage partners.

2. How prior marriages terminated (death, divorce, annulment).

3. The date prior marriages terminated (month and year at a minimum).

4. The place prior marriages terminated (city and state).

If there is a conflict in the marital evidence submitted and the evidence of record, request a certified copy or certified abstract of a final divorce decree, or an uncertified photocopy that is deemed to be genuine and free from alteration by VA.

 

References:

M21-1, Part III, 6.07d & i

M21-l, Part III, 1.07a

M21-1, Part IV, 12.03 f

38 CFR 3.204, 3.206

C&P Fast Letter 4-92 (9/14/94)

  

PARENTAL RELATIONSHIP

If claiming parent(s) as dependents, we need an original birth certificate, a certified copy of the veteran's birth certificate which has been certified by the custodian of the records, or an uncertified photocopy that is deemed to be genuine and free from alteration by VA. A copy may also be certified by a VA employee, an accredited representative of a Veterans Service Organization, or a military or civilian personnel appointed on orders for this purpose by the commander of a military installation.

 

 

References:

M21-1, Part III, 6.01

M21-1, Part III, 6.23-6.31

M21-1, Part IV, Chapter 13

38 CFR 2.50

38 CFR 3.59

C&P Fast Letter 4-92 (9/14/94)

 

CHILD RELATIONSHIP

 Birth

Primary evidence is the original birth certificate, a certified copy from the custodian of the record, or an uncertified photocopy that is deemed to be genuine and free from alteration by VA. The custodian of birth records is generally the State Department of Records or Vital Statistics in the state where the child was born.

An alternate form of evidence to document the birth of a child may be submitted as secondary evidence. (See Reference).

References:

M21-l, Part III, 6.17

38 CFR 3.209

38 CFR 3.204

C&P Fast Letter 4-92 (9/14/94)

  

Legitimate Child

Evidence will be required to establish the legality of the marriage of the mother of the child to the veteran or to show that the child is otherwise legitimate by state laws together with evidence of birth as described in the section on Birth.

(M21-1, Part III, 6.18, 6.19)

 

 

 

Illegitimate Child

As to the mother of an illegitimate child, proof of birth of the child is all that is required. As to the father, the evidence will be determined in accordance with the facts in the individual case.

(M21-1, Part III, 6.18, 6.19b)

  

Adopted Child

A certified copy of the decree of adoption or the adoptive placement agreement, or an uncertified photocopy of either which is deemed by VA to be genuine and free from alteration. A certified copy of the child's revised birth certificate (or an uncertified photocopy deemed to be genuine and free from alteration by VA) may be accepted to establish the child from the date of receipt of the birth certificate.

(M21-1, Part III, 6.20)

 

Stepchild

A birth certificate showing names of natural parents, evidence of the marriage of the veteran to the natural parent of the child and evidence the child is a member of the veteran's household.

(M21-1, Part III, 6.21)

  

Helpless Child

Any communication or evidence indicating or claiming permanent incapacity for self-support of a child of a veteran. Request claimant submit medical evidence of physical and/or mental condition which shows the disability existed at the age of 18. Claimant should also submit statements from teachers, tutors or social workers, who have observed the child.

(M21-1, Part IV, 15.02, 15.03)

 

 Basic Dependency References:

M21-1, Part III, 6.17, 6.18, 6.19, 6.20, 6.21

38 CFR 3.204, 3.209, 3.10

38 CFR 3.57, 3.58

38 CFR 3.403 (e)

C&P Fast Letter 4-92 (9/14/94)

 G. Income Development

Eligibility for VA non-service-connected pension benefits and parents' Dependency and Indemnity Compensation (DIC) is contingent on, among other things, the claimant's income. The claimantsí net worth is a factor in determining eligibility for Section 306 and Improved Pension. Net worth is not a factor in Old Law pension and parents DIC cases.

If gross income from all sources exceeds the applicable limit (See M21-1, Part I, Appendix B), deny claim because of excess income. If special monthly pension is a factor, use the A&A or housebound income limit. Unreimbursed medical expenses and educational expenses paid after date of claim may be used to reduce income.

If gross income from all sources is less than the applicable limit established by law in M21-1, Part I, Appendix B, develop claim as shown in Sections III and IV of this training guide.

The general rule set out in 38 CFR 3.271 is that all income is countable unless specifically excluded by 38 CFR 3.272. (M21-1, Part IV, 16.41a(1))

 

Income Development: M21-1, Part III, 7.02, 7.05

 

Income Counting Procedures: M21-1, Part IV, 16.23

  

Countable Income M21-1, Part IV, 16.41c

 

Countable monthly income includes (but is not limited to):

Income from retirement or survivors programs, interest, dividends, Social Security (Not SSI), Civil Service, military retirement, black lung, and other recurring monthly income.

 

Countable annual income includes (but is not limited to):

Wages/salary, business/rental income, farm income, Indian income (M21-1, Part IV, 16.43 a-h), interest/dividend income, Worker's Compensation, Unemployment Compensation, insurance payments or dividends.

 

 

What Income is Excludable?

(What does not count as income?) M21-1, Part IV, 16.41a-b; 38 CFR 3.271-2

 Exclusions include (but are not limited to):

SSI (Supplemental Social Security), maintenance (room and board), proceeds of casualty insurance, profit from occasional sale of property, agent orange settlement payments, royalties for extracting minerals from the ground, income tax refunds, withheld Social Security, interest on IRA's (Individual Retirement Accounts), and scholarships and grants for school attendance (if not in excess of actual expenses), redress payments to WWII Japanese internees, and interest on irrevocable burial trusts.

 

Income Classifications: one time, recurring, non-recurring

 M21-1, Part IV, 16.22

 

 Income Reporting Periods:

 M21-1, Part III, 7.01e

  

Income of Parents: Dependency and Indemnity Compensation (DIC)

 38 CFR 3.251

  

Income Verification Match (IVM):

 VBA Circulars 20-91-11R (2-22-93), 21-92-7, paragraph 2e,

Fast Letter 3-54

  

Deductible Expenses:

 M21-1, Part IV, 16.30

  

Development of Medical Expenses:

 38 CFR 3.262 and 3.272

M21-1, Part III, 7.06

 

Prospective Medical expenses: M21-1, Part IV, 16.31(10)(d)

M21-1, Part III, 7.06

List of possible Medical expenses:

M21-1, Part IV, Chapter 16, Addendum A)

 

Development of Final Expenses:

 M21-1, Part III, 7.07

M21-1, Part IV, 16.32

  

Development of Educational Expenses:

 M21-1, Part III, 7.08

M21-1, Part IV, 16.34b

 

  

Development of Child Hardship Exclusion:

 M21-1, Part III, 7.09

M21-1, Part IV, 16.34c

  

Net Worth Development:

 M21-1, Part III, 7.10

 

The basic issue in evaluating net worth is whether or not the claimant's financial resources are sufficient to meet the claimant's basic needs without assistance from VA.

No specific dollar amount can be designated as excessive net worth. What constitutes excessive net worth is a question of fact for resolution after consideration of the facts and circumstances in each case.

Net worth includes the value of real estate (except the claimant's single family dwelling), value of personal property, cash, stocks, bonds, bank accounts, CD's, IRA's, Mutual funds, Keoghs, business assets and any other property.

If net worth is over $50,000, send claimant VA Form 21-8049. (For $50,000 limit, see change 52 dated 5-19-94, M21-1, Part IV).

 

Section II

Compensation

A. Background II-1

B. Developing Original (EP 010 or 110) II-6

C. Developing Reopened Claims (EP 020) II-8

1. Condition previously denied II-8

2. Condition not previously denied (new) II-9

3. Claim for increase II-9

D. Specific Claims Issues II-10

1. Exposure to Herbicide Agents II-11

2. Asbestos II-14

3. POW claims II-15

4. Mustard Gas II-17

5. Post Traumatic Stress Disorder II-19

6. Radiation Exposure II-24

7. Conditions Secondary to Drug/Alcohol II-28

8. Smoking II-29

9. 1151 Claims II-30

10. Toxic Chemical Exposure Claims II-32

11. HIV/AIDS II-33

12. PGW/Environmental Agents II-34

 

 

A. Background

A decision to establish service connection is in order if the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or, if preexisting such service, was aggravated while in service.

 

The development of evidence to support a determination of service connection may include four elements:

 

1. Service Medical Records

2. Continuity - evidence of ongoing treatment from military service to present.

3. First treatment - evidence to show the first treatment for the claimed disability following service.

4. Recent treatment - evidence to show recent treatment and current severity for the claimed condition. In many cases this will be a VA examination.

5. In the case of preexisting conditions, request treatment prior to service.

 

Service Medical Records (SMR)

 In all cases you will need SMRs.

 

 Continuity

You may need evidence of continuity of treatment (treatment since discharge.). The request for continuity will depend on whether the disability is chronic in nature. Chronicity may be established in one of three ways:

1. By definition (regulation): 38 CFR 3.309 defines those conditions that are chronic by definition. If these conditions are shown to exist in service or manifested to a compensable degree within the presumptive period (generally one year) following service, service connection is generally warranted. In this situation continuity of treatment for the claimed condition after service is not required. However, you may need to request evidence of treatment within the first year following military service.

2. By traumatic injury or surgical treatment in service with probable residuals. The residual can be as simple as a surgical scar. Examples include a shell fragment wound, a fractured bone, or a hernia repair. In this situation, continuity of treatment for the claimed condition after service is not required.

3. By repeated occurrences or episodes: 38 CFR 3.303(b) provides: for the showing of a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings, or a diagnosis including the word chronic. When the disease entity is established (See 38 CFR 3.309), there is no requirement of evidentiary showing of continuity.

  

Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic as stated in 1, 2 and 3 above. Examples of non chronic conditions include pneumonia, acute low back strain or acute bronchitis.

Requests for Continuity of Treatment: In those cases where the claimed disability is shown to be chronic in nature, you do not need to request continuity of treatment.

 

First Treatment

Evidence to show first treatment following service will be used to identify the first manifestations and medical treatment for the claimed conditions.

Recent Treatment

 You may need recent treatment depending on how long after service the claim for service connection is made. In those cases where the claim is filed shortly (within 6 months) after discharge, there is no need to request evidence of recent treatment. If the appropriate information and release forms are provided on the application, action should be taken to ensure all available evidence is of record when the decision is made. This ensures we have met our duty to assist as defined by the Court of Veterans Appeals.

 

Direct Service Connection

A disability determined to be service-connected due to service or aggravated by service. It is either shown in the SMR treatment record, or on discharge exam. VA exam may be requested to establish current level of disability or residual of an acute disease or injury.

Direct service connection may also be established for a condition which existed prior to entry into service (EPTE) and was aggravated beyond its natural progression during the veteran's period of service. (38 CFR 3.304 and 3.305)

 

Presumptive Service Connection:

A disability may be service-connected if it falls into certain categories and was incurred during time frames established by legislation.

 

Chronic diseases may be service-connected if they are manifest to a percent of 10% or more within 1 year of discharge. Tuberculosis and Hansen's Disease may be service connected if it is manifest to a percent of 10% or more within 3 years of discharge and Multiple Sclerosis if manifest to a percent of 10% or more within 7 years.

38 CFR 3.309(a)

  

Tropical diseases may be service-connected if manifest within 1 year of discharge or due to the administration of therapy or preventive therapy.

 

M21-1, Part IV, 5.05

38 CFR 3.307

38 CFR 3.309(b)

38 USC 1112

 

Diseases specific to POWs may be service-connected if manifest to a percent of 10% or more anytime after discharge from service

38 CFR 3.307

38 CFR 3.309(c)

 

Diseases associated with Exposure to Certain Herbicides may be service-connected if a qualifying disability exists. Different time frames and percentage requirements exist for each new piece of legislation covering this area.

38 CFR 3.307(a)(6)

38 CFR 3.309(e)

 

Diseases associated with Exposure to Ionizing Radiation may be service-connected if a qualifying disability exists under one of two laws.

M21-1, III, 5.12

Fast Letter 3-126

38 CFR 3.309(d)

38 CFR 3.311

 

B. Developing Original (EP 010 or 110 series)

(38 CFR 3.170d(b))

 

The application should be reviewed to ensure veteran has claimed a disability. If no specific disability has been claimed, or the disability is unclear, the veteran should be asked for clarification. All other development should be requested at the same time.

 

Request SMRs (if not already in) in accordance with M21-1, Part V, Chapters 17.04 and 17.05 (Target 201 & 202 screens) and M21-1, Part III, Chapter 4 (address codes). A quick reference guide for address codes is provided at the end of this section. Veteran should be asked for any service medical records in his possession.

 

Develop for any necessary private medical treatment mentioned in the veteran's claim as follows:

 

1. If the veteran does not provide release forms for any claimed private treatment, send the necessary number of VA Form 21-4142 to the veteran via the Target 203 screen.

2. If release forms are provided for private treatment records, send the forms along with VA Form Letters 21-104 or 21-107 or local letter, as appropriate to the hospital or doctor that provided the treatment. As a local option, a letter may be sent to the veteran at the same time, requesting assistance from the veteran in obtaining the medical evidence.

3. If the doctor or hospital does not respond within 60 days, request the veteran to assist in obtaining the records by using the Hospital/Doctor field on the Target 203 screen. Enter the appropriate hospital or doctor in the required field.

Request any necessary reports from any claimed VA treatment via a hard copy 7131 or AMIE request as appropriate.

If any condition is one listed under Specific Claims Issues follow the steps listed for that type of claim in addition to development needed for any other claimed disabilities.

If veteran is more than one year from discharge or the condition is not presumptive for the type of claim filed and supporting private medical information is not provided, request Treatment Since Discharge on the Target 203 screen.

If veteran's SMRs do not show treatment for the claimed condition or the veteran specifically states that no treatment was received in service, request Treatment For on the Target 203 screen.

If veteran's service falls within a possible fire related period, send a NA Form 13055 to the veteran and develop for alternate sources. Any alternate sources that may have been identified on the application should be developed at the same time.

If veteran indicates treatment at a military hospital subsequent to service, request the records using VA Form 21-8359 if appropriate.

If claim involves injuries from a vehicle accident, request Line of Duty (LOD) determination from the service department if it appears line of duty is an issue and request Accident from veteran on Target 203 screen.

If civilian authorities may have been involved, send a request for the police report.

If reserve or national guard duty is involved, request verification of active duty dates and ask veteran to provide proof of duty status when disability was incurred.

 

After development is complete, claim should be forwarded to the Rating Activity for review of development and consideration for exam.

 

C. Developing Re-opened Service Connected Claims (EP 020 series)

1. Condition previously denied service connection :

With the exception of reopened PTSD claims, if the veteran does not submit new and material evidence to reopen claim, inform veteran that claim was previously disallowed, the date of the disallowance and the reasons for disallowance. Veteran should be informed he must submit new and material evidence to reopen claim. He should be given 60 days to submit the new and material evidence. The claim should be kept under end product control.

If the veteran submits medical evidence, the case should be referred to the rating board to determine if evidence is new and material.

If veteran indicates where to obtain new and material evidence to reopen claim, develop for any relevant private medical treatment mentioned in the veteran's claim if it is not already of record as follows:

If the veteran does not provide release forms for any claimed private treatment, send the necessary number of VA Form 21-4142 to the veteran via the Target 203 screen.

If release forms are provided for private treatment records, send the forms along with VA Form Letters 21-104 or 21-121 or local letters as appropriate to the hospital or doctor that provided the treatment. As a local option, a letter may be sent to the veteran at the same time, requesting assistance from the veteran in obtaining the medical evidence.

If the doctor or hospital does not respond within 60 days, request the veteran to assist in obtaining the records by using the Hospital/Doctor field on the Target 203 screen. Enter the appropriate hospital or doctor in the required field.

Request reports of any claimed VA treatment which is not already of record via AMIE or VA Form 10-7131 if necessary.

 

2. Condition not previously denied service connection (i.e. a new condition):

Develop as if for an original service connection claim (See B in this section)

3. Condition already service connected (Claim for increase):

If veteran does not indicate any treatment for a service connected disability, use the Target 208 screen Request for evidence SC increase claimed field.

Develop for any recent (treatment in preceding year) private medical treatment mentioned in the veteran's claim if it is not already of record as follows:

 

If the veteran does not provide release forms for any claimed private treatment, send the necessary number of VA Form 21-4142 to the veteran via the Target 203 screen.

If release forms are provided for private treatment records, send the forms along with VA Form letters 21-104 or 21-107 or local letter, as appropriate to the hospital or doctor that provided the treatment. As a local option, a letter may be sent to the veteran at the same time, requesting assistance from the veteran in obtaining the medical evidence.

If the doctor or hospital does not respond within 60 days, request the veteran to assist in obtaining the records by using the "Hospital/Doctor" field on the Target 203 screen. Enter the appropriate hospital or doctor in the required field.

Request reports of any claimed VA treatment which is not already of record by using a hard copy 7131 or AMIE request as appropriate.

Do not request Treatment Since Discharge. Continuity is not an issue for a condition which is already service connected.

 

D. SPECIFIC CLAIMS ISSUES

Issues in which specialized development are needed and the issues are of special interest to the Department or Congress.

Some issues are monitored using the Special Issue Rating System (SIRS).

Terminal digits on end products are used to designate some issues.

2 - Ionizing Radiation

3 - POW

4 - PTSD

5 - Exposure to Herbicide Agents

9 - Persian Gulf War (PGW)

The SIRS system allows entries for asbestos, HIV/AIDS, Exposure to Herbicide Agents, POW, PTSD, and Ionizing Radiation claims.

  

Other Specific Claims Issues addressed in this section include:

Toxic Chemical Exposure Claims

Smoking/Tobacco claims

Mustard Gas Claims

Persian Gulf War claims to include Environmental Agent Exposure

M21-1, Part V, Chapter 14

1. Exposure to Herbicide Agents:

If a specific disability is not claimed, request Nature of Disability via the Target 203 screen.

If the claimed disability is not a qualifying disability recognized as a presumptive residual of exposure to herbicide agents, consider the claim for direct service connection and develop as necessary.

Those conditions which are associated with exposure to herbicide agents are as follows:

 * Chloracne or other acne form disease consistent with chloracne

* Hodgkin's disease

* Non-Hodgkin's Lymphoma

* Porphyria cutanea tarda (a skin condition)

* Multiple Myeloma

* Respiratory cancers (cancer of the lung, bronchus, larynx or trachea)

* Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma,

Kaposi's sarcoma, or mesothelioma)

 

NOTE: The term soft-tissue sarcoma includes the following:

 

Rhabdomysarcoma

Ectomesenchymoma

Malignant glomus tumor

Malignant hemangiopericytoma

Synovial sarcoma (malignant synovioma)

Malignant giant cell tumor of tendon sheath

Malignant Schwannoma

Malignant mesenchymoma

Congenital and infantile fibrosarcoma

Epithelioid sarcoma

Adult fibrosarcoma

Dermatofibrosarcoma protuberans

Malignant fibrous histiocytoma

Liposarcoma

Leiomyosarcoma

Malignant granular cell tumor

Alveolar soft part sarcoma

Extraskeletal Ewing's sarcoma

Malignant ganglioneuroma

Epithelioid Leiomysarcoma (malignant meiomyblastoma)

Angiosarcoma (hemangiosarcoma and lymphangiosarcoma)

Proliferating (systemic) angioendotheliomatosis

Clear cell sarcoma of tendons and aponeuroses

 

 Develop for:

 Proof of exposure

 Service in the Republic of Vietnam

Includes the waters offshore

Service in other countries if the conditions of service involved duty or visitation in the Republic of Vietnam

If no evidence of Vietnam service is present, request personnel file/201 file from appropriate address code.

Exposure is conceded if proof of service in the Republic of Vietnam is shown. No special development letter is required. If a veteran served in Vietnam or the adjacent waters, it is presumed he/she was exposed to herbicide agents.

Disability claimed as a residual to the exposure.

Develop any medical evidence if need to do so is indicated.

Notify veteran he may have an Exposure to Herbicide Agents Protocol exam at any VA Medical Center. If veteran has had one they should notify VARO.

Obtain copy of Exposure to Herbicide Agents Protocol exam if indicated.

 

References:

38 USC 1116

38 CFR 3.307(a)(6)

38 CFR 3.309(e)

38 CFR 3.313

M21-1, Part III, 5.10

VBA Circular 21-94-1

  

3. POW Claims:

Verify the veteran's POW status through the service department. Obtain POW internment dates and place.

If the location of internment was in a neutral or allied country, develop information concerning conditions of the internment.

If the claimed disability is a presumptive condition for former POWs, no development is required to establish continuity. POW presumptive conditions are as follows:

 

Avitaminosis

Beriberi (including Beriberi heart disease)

Chronic dysentery

Helminthiasis

Malnutrition (including optic atrophy associated with malnutrition)

Pellagra

Any other nutritional deficiency

Psychosis

Any of the anxiety states

Dysthymic disorder (or depressive neurosis)

Organic residuals of frostbite (provided veteran was in such a climate)

Post-traumatic osteoarthritis

Irritable bowel syndrome

Peptic ulcer disease

Peripheral neuropathy (except where related to infectious causes)

 

If the claimed disability is not presumptive, develop for any treatment mentioned in the veteran's claim. If none is provided, request Treatment Since Discharge via Target 203 screen.

The veteran is entitled to POW Protocol exam. All claims where POW status is verified and no protocol exam is of record, VA exam - POW Protocol must be requested.

If no record of treatment exists in the veteran's SMRs and the condition is not presumptive, request Treatment For on the Target 203 screen.

 

 Ischemic Heart Disease:

This involves POW cases only. The issue at hand is service connection for this condition on a presumptive basis for former POWs such as VA now does for irritable bowel syndrome and other conditions.

Develop for any medical treatment the veteran mentions on his/her claim.

 

Treatment Since Discharge (continuity) is not required.

 References:

M21-1, Part IV, 3.06a

M21-1, Part VI, 1.02c

M21-1, Part VI, 7.71

38 CFR 3.307

38 USC 1112

Judicial Review Conference call 11/4/93

C&P Service Fast Letter 4-69 (7-18-94)

C&P Service Fast Letter 4-72 (7-19-94)

 4. Mustard Gas Exposure:

If the claimed disability is not one of the following, develop for direct or presumptive service connection, do not do any development for mustard gas exposure:

Laryngitis

Bronchitis

Emphysema

Asthma

Conjunctivitis

Keratitis

Corneal opacities

 

If a specific disability is not claimed, request Nature of Disability via Target 203 screen. Simultaneously develop for any medical treatment the veteran mentions on his/her claim. If none provided, request Treatment Since Discharge via Target 203 screen and send development letter for details of exposure if not already clarified. (At local option, all of these paragraphs may be combined in a dictated or local pattern letter).

When disability and exposure have been clarified, call VACO as follows:

Rating Procedures (213D) at (202) 273-7249

Advisory Review (211C) at (202) 273-7210

When veteran responds to development letter, send letter to Service Department. requesting any record of veteran's exposure.

 NAVY: - When a claim is received alleging exposure at Naval Research Laboratory (NRL) call VACO to verify if the veteran's name is on their list of Navy participants. Claims alleging exposure at places other than NRL will be developed via 3101 to NPRC (Code 13)

 ARMY - Call VACO to verify if the veteran is on the VA's Epidemiology Service list of mustard gas testing/training. If the veteran is not on the list simultaneous development to NPRC (Code 13) and to one of the following addresses should be taken:

 ARMY TESTING which Occurred Prior to 1955

Commander

US Army Chemical and Biological Defense Agency

ATTN: AMSCB-CIH

Aberdeen Proving Ground, MD. 21010-5423

 ARMY TESTING which Occurred Between 1955 and 1975

Headquarters

Army Medical Research and Development Command

Fort Detrick

Frederick, MD. 21702-5012

ATTN: SGS

 

Send deferral letter after review by the rating board.

  

References:

38 CFR 3.316 (July 31, 1992)

C&P Service Fast Letter 2-135 (11/13/92)

C&P Service Fast Letter 3-1 (1/6/93)

C&P Service Fast Letter 3-31 (3/10/93)

C&P Service Fast Letter 4-53 (5/24/94)

VBA Circular 21-91-7

 

 5. Post Traumatic Stress Disorder (PTSD): -- CFR 3.304f

 

Purple Heart Navy Expeditionary Medal

Medal of Honor Air Medal (with "V" for Valor)

Distinguished Service Cross Combat Action Ribbon

Navy Cross Combat Medical Badge

Air Force Cross Distinguished Flying Cross

Silver Star Bronze Star (with "V" for Valor)

Air Force Commendation Medal (with "V" for valor)

Parachutist Badge with Bronze Service Star

Joint Service Commendation Medal (with "V" for valor)

Army Commendation Medal (with "V" for valor)

Navy Commendation Medal (with "V" for valor)

 

If the veteran does not have one of the above decorations or if he does not have a combat military occupational specialty (MOS), and the claim is for a combat related event, send development letter to the veteran and request the veteran's Personnel file/201 file from the Service Department. To aid in the securing of information to support the claim, the "Information in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD)" (copy follows) should be attached to the development letter sent to the veteran.

If the claim is for a non-combat related event, send development letter to the veteran and request the veteran's Personnel file/201 file from the Service Department. To aid in the securing of information to support the claim, the "Information in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD)" (copy follows) should be attached to the development letter sent to the veteran.

Only when available evidence is insufficient to establish a stressor should a letter be sent to Environmental Support Group (ESG) to verify the stressor. VA medical facility personnel have been asked to include a completed "Evidence Necessary for ESG Verification of Stressor" (copy follows) when preparing a VA examination report for PTSD. A copy of this document should also be attached to the letter to ESG.

 

Information in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD)

  

Evidence Necessary for ESG Verification of Stressor

 

The goal of an Environmental Support Group (ESG) search is verification of the claimed stressor for PTSD. The stressor is defined in the DSM-III-R, p. 250: "...an event that is outside the range of usual human experience that would be marked distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relative or friends; sudden destruction of one's home or community; seeing another person who has recently been or is being, seriously injured or killed as a result of an accident or physical violence." This covers not only traditional combat situation stressors, but also war zone related experiences such as serving in MASH units, graves registration units; or being a survivor of a sexual assault while on active duty.

 Provide the information necessary to begin an ESG search for stressor verification as described in the Mental Health & Behavioral Sciences Manual: M-2, Part X, Chapter 2, June 29, 1993, page 2-6, f. (2) (a)-(d) outlining the "clear and concretely detailed description of the stressor(s)".

6. Ionizing Radiation Exposure:

Disease related to Ionizing Radiation exposure may fall into one of three categories.

 

Exposure may be due to:

participation in the occupation of Nagasaki/Hiroshima

participation in atmospheric testing

occupational exposure

 

If a specific disability is not claimed, request Nature of Disability via Target or local letter.

If the claimed disability is not one associated with radiation exposure under 38 CFR 3.309 or 3.311b (presumption), consider the disability or disease for direct service connection.

 a. Exposure due to atmospheric testing or Hiroshima/Nagasaki (38 CFR 3.309)

Radiation related diseases under 38 CFR 3.309 for veterans who participated in atmospheric testing or Hiroshima/Nagasaki are listed below:

Cancer of the thyroid Cancer of the pancreas

Cancer of the breast Multiple myeloma

Cancer of the pharynx Cancer of the gall bladder

Cancer of the esophagus Cancer of the bile ducts

Cancer of the stomach Cancer of the salivary gland

Cancer of the small intestine Cancer of the urinary tract

Lymphomas (except Hodgkin's disease)

Leukemia (other than chronic Lymphocytic leukemia)

Primary liver cancer (except if cirrhosis or hepatitis B is indicated)

 

b. Exposure as a result of the veteran's job classification or as a result of atmospheric testing and Hiroshima/Nagasaki (38 CFR 3.311b)

 

Radiation related diseases under 38 CFR 3.311b are listed below. All diseases must become manifest 5 years or more after exposure unless otherwise noted.

Thyroid cancer Stomach cancer

Breast cancer Colon cancer

Lung cancer Pancreatic cancer

Liver cancer Kidney cancer

Skin cancer Urinary Bladder cancer

Esophageal cancer Salivary gland cancer

Ovarian cancer Multiple Myeloma

Parathyroid adenoma

Non-malignant thyroid nodular disease

Bone cancer (must be manifest within 30 years after exposure)

Posterior subcapsular cataracts (must be manifest 6 months or more after exposure)

All forms of Leukemia except chronic lymphatic leukemia. (Can be manifest at any time after exposure).

 

 Development

 

Direct Service Connection: Follow regular development procedures.

  

Presumptive Service Connection:

38 USC 1112, 38 CFR 3.309

 Verify that a qualifying disease or disability is claimed

Obtain medical evidence with a diagnosis

Send appropriate development letter to the claimant to verify participation only

Go to Defense Nuclear Agency (DNA)

 

 

 

38 CFR 3.311

 Verify that a qualifying disease or disability is claimed

Obtain medical evidence with a diagnosis

Send appropriate development letter to the claimant

Process 201/202 to service department for dosimeter information (For Occupational exposure claims only)

Contact VACO C&P Service

Write to Defense Nuclear Agency (DNA)

 

Send:

 Memorandum request for information

Copy of reply to development letter

Copies of any pertinent service department information

Verify dosimeter and participation information

 

7. Conditions Secondary to Drug or Alcohol Use/Abuse

If a specific disability is not claimed, request Nature of Disability via Target or local letter.

These claims involve service connection for conditions secondary to drug/alcohol use/abuse. Regulations already exist by which VA must deny direct service connection for drug/alcohol use (though it can still be service connected as being secondary to a service connected condition such as PTSD). However, denials of service connection for conditions secondary to drug/alcohol abuse, such as liver damage due to alcohol abuse, are being deferred.

 Send deferral letter when the deferred rating is completed.

 

References:

M21-1, Part VI, 7.41 and 7.42

C&P Service Fast Letter 2-107 (9/16/92)

 

 

 8. Smoking Claims:

If a specific disability is not claimed, request Nature of Disability via Target 203 screen. Simultaneously develop for any medical treatment the veteran mentions on his/her claim. If none provided, request Treatment Since Discharge via Target 203 screen and send development letter regarding smoking history if not already clarified. (At local option, all of these paragraphs may be combined in a dictated or local pattern letter).

 No action can be taken to deny these claims.

 Send deferral letter.

 Put on log to control.

 

References:

OGC 2-93

Judicial Review Conference calls 6/3/93(addendum 2) and 11/4/93

  

9. 1151 Claims:

 Claims for compensation due to treatment at a VA facility (38 USC 1151).

 If specific disability is not claimed, request Nature of Disability via Target.

Veteran must provide date and location of treatment. If this is not provided, send a letter to the veteran requesting the date, nature, and location of the treatment in question. Request any medical treatment records for subsequent treatment.

Send request ( memorandum or letter) for information to the VA Medical Center addressed to the Chief of Staff with this information:

what the veteran is claiming

nature of the surgery or other involved procedure

dates of the surgery or other involved procedure

place ofthe surgery or other involved procedure

 

AND ASK FOR:

copies of all treatment records regarding the claim to include:

 

Hospitalization reports

Outpatient treatment records

Nurses notes

Physicians notes

Surgical reports

Subsequent treatment records if any

Progress notes (on SF 509 or other form)

Consent Form (SF 522)

 

Refer to the Rating Board for review.

  

References:

38 USC 1151

38 CFR 3.358

C&P Service Fast Letter 5-09 (2-1-95)

M21-1, Part IV, 6.06

Brown v. Gardner, U.S.Sup.Ct. No. 93-1128 (12-12-94)

 

 10. Toxic Chemical Exposure:

 Request specific disability claimed

Send Development letter

Obtain any medical evidence available

Request VA exam if indicated

 

These types of claims are for Direct Service Connection consideration and are usually occupational exposures.

 

11. HIV/AIDS:

Obtain medical evidence

If indicated, obtain pre-induction HIV screening

 

References:

M21-1, Part II, 3.05

M21-1, Part III, 5.15

 

12. Persian Gulf War Claims:

 To include environmental agents claims:

 Obtain proof of service in the Persian Gulf.

Develop nature of disability if not indicated.

 

If a valid PGW claim exists:

Flash the claims folder.

Send letter to veteran.

E-mail PGW RPO servicing veteranís home address.

Transfer the claims folder to the servicing RPO.

 

References:

VBA Circular 20-92-29, Revised

C&P Fast Letter 4-126

  

Section III

Live Pension

A. Original Pension Claims (EP 180) III-1

B. Reopened Pension Claims (EP 120) III-2

 

A. Original Pension Claims (EP 180)

1. If veteran does not provide recent medical information (within about 6 months of current date), request Recent Treatment via Target 203 screen (Do not request Treatment For or Hospital/Doctor. These are SC fields). Use dictated letter if necessary.

2. Develop for any recent medical treatment mentioned on the veteran's claim.

3. Ensure dependency and income information is complete. If income is not complete, return for completion. If additional information is required to establish a claimed dependent, request the information via the Target 204 screen.

4. If income is excessive, claim should be denied as basic eligibility does not exist.

5. If Net Worth is $50,000 or greater, request 8049-General via Target 203 screen.

 

References:

M21-1, Part III, Chapters 5, 6 & 7

M21-1, Part IV, Chapters 12 & 16

M21-1, Part VI, Chapter 8, Subchapter I (SMP)

38 CFR 3.3(a)

38 CFR 3.260

38 CFR 3.270

  

B. Reopened Pension Claims (EP 120)

1. If veteran does not provide recent medical information (within about 6 months of current date), request Recent Treatment via Target 203 screen (Do not request Treatment For or Hospital/Doctor. These are SC fields). Use dictated letter if necessary.

2. Develop for any recent medical treatment mentioned on the veteran's claim.

3. Ensure dependency and income information is complete. If income is not complete, return for completion. If additional information is required to establish a claimed dependent, request the information via the Target 204 screen.

4. If income is excessive, claim should be denied as basic eligibility does not exist.

5. If Net Worth is $50,000 or greater, request 8049-General via Target 203 screen.

 Section IV

Death Claims

A. Dependency and Indemnity Compensation

(DIC) IV-1

B. Death Pension IV-3

C. Burial Development IV-4

D. Accrued Claims IV-5

 

A. Dependency and Indemnity Compensation (DIC)

(EP 140)

A VA Form 21-534 is a claim for three benefits: DIC, Death Pension and Accrued. All three must be addressed, even though it may appear the claimant is not actually claiming all three.

A VA Form 21-535 is a claim by a parent(s) for DIC only.

Initial development should include concurrent requests for any needed evidence including SMRs, service verification, character of discharge, continuity or chronicity, treatment reports and private medical records, autopsy reports, terminal hospital summary, Social Security numbers, relationship of claimant to the veteran, and a certified copy of death certificate. (For evidence requirements, see M21-1, Part VI, 5.03)

DIC claims are filed by surviving spouses, children, or parents of veterans who believe the veteran's death resulted from injury or disease related to the veteran's service.

Refer the case to the rating board for a rating if all development is complete and any of the following situations exist:

1. The veteran died within 5 years of separation of service unless death was due to homicide, execution, accident or disaster.

2. Service connection was previously granted for a cardiovascular or genitourinary condition or chronic disease (in 38 CFR 3.309), or service connection was granted for any other vital organ.

3. The veteran had at least one service-connected disability evaluated at 50 % or more.

4. The veteran had been in receipt of total service-connected disability benefits (including entitlement to Individual Unemployability) for 10 years or more immediately preceding death.

5. The veteran died within 10 years of discharge and he had a totally disabling service-connected condition continuous from discharge until death, providing such period is at least 5 years.

 

6. The veteran died of suicide, or if there is probability of misconduct, or if death occurs within first 6 months of active duty.

7. The claimant has specifically raised the issue of service connection for the cause of death including DIC under 38 USC. 1151.

 

Exception: If the claim for DIC is filed by a parent, and the income is excessive for receipt of DIC, disallow the claim for excessive income and notify the claimant that no other aspect of the claim has been considered.

Note: Refer any case to the rating board , whether or not it fits into one of the above categories, if there is a question as to the cause of death.

A rating is not required and we accept that death is service-connected if veteran died in service from disease or armed conflict, as well as service persons who were missing and presumed dead by the service department. Refer these cases to authorization.. (Award should be annotated: Cause of death due to service, M21-1, Part III, paragraph 3.06.)

  

References:

38 CFR 3.5

M21-1, Part III, 3.06, 3.07, 3.09

M21-1, Part IV, 26.18

M21-1, Part VI , 5.01-5.14.

 

B. Death Pension (EP 190)

Surviving spouse or children filing for income based pension benefits following the death of a qualified veteran. (Qualified veteran had at least 90 days active, honorable service with at least one day of wartime service.) Veteran did not die as a result of a service-connected disability.

If a veteran had wartime service, but had less than 90 days active duty, refer the case to the rating board unless one of the conditions in M21-1, Part III , 3.07(3) exist.

Surviving spouse or children must have total gross income which is under the limit on rate charts in Appendix B.

If veteran had qualifying service, and spouse's or children's income is under the limit in M21-1, Part I, Appendix B, award benefits immediately.

 

 

 

References:

38 CFR 3.3(b)

M21-1, Part III, 3.07

M21-1, Part VI, 5.07

 

C. Burial Development (EP 160)

 

Eligibility Criteria

 

Non Service Connected

1. In receipt of pension or compensation at time of death.

2. In receipt of military retired pay in lieu of compensation.

3. Had, at time of death, original or reopened claim pending and has been found entitled to compensation or pension prior to date of death.

4. Died while hospitalized by VA.

5. Died while traveling under proper authorization at VA expense to or from specified place for purpose of examination, treatment or care. (M21-1, Part III, 13.08)

 

Service Connected

1. Rating board must prepare a favorable rating decision granting service connection for cause of death (direct or indirect).

2. All claims should be considered a claim for service connection even though not placed in issue. See M21-1, Part III, 3.07 for instructions on when to submit case to the rating board. (M21-1, Part III, 13.31)

 

Plot Allowance: 38 CFR 3.1600(f); M21-1, Part III, 13.53

Acceptable Proof of Death: 38 CFR 3.211; M21-1, Part III, 13.10b

Receipted Bills: 38 CFR 3.1601(b)(2); M21-1, Part III, 13.10c

Burial in National Cemetery: 38 CFR 3.1610) (M21-1, Part III, 13.18

Transportation: 38 CFR 3.1600(g); M21-1, Part III, 13.74-13.79

Death in VAMC: 38 CFR 1605; M21-1, Part III, 13.08(4)&(5), 13.74

 

See also:

M21-1, Part III, Chapter 13

38 CFR 1600-1612

 

D. Accrued Claims (EP 165)

This benefit is payable only one time, but may be paid in parts to separate relatives or creditors.

 

References:

38 CFR 3.1000 (d)

M21-1, Part IV, Chapter 27

 

 Section V

 

 AMIE Checklist V-I

 

AMIE Checklist

 

 A. Ordering a new 2507 exam

 1. From main menu, select option 17 (RO C&P menu).

2. Select 1 (New C&P request).

3. Enter first letter of last name & last 4 digits of SSN.

4. For last exam, enter T.

5. Follow prompts as they appear. Many exam types may be entered by typing first 3 letters of description. Otherwise, enter exam type as it appears on the exam request worksheet. If provided, enter the diagnostic code(s) and diagnosis(es) to be examined in the remarks section.

6. After all exam types have been entered, hit return.

7. Back out of AMIE as normal.

8. On Target 208 screen, check pending claim, and type UPD for next screen. Then update suspense date for 60 days from date of exam request.

  

B. Checking on the status of a previous 2507 exam request.

1. From main menu, select option 17 (RO C&P menu).

2. Select 5 (Inquiry for C&P requests).

3. Enter first letter of last name and last 4 digits of SSN.

4. If no exam request is found, a message will now appear, and the exam request may need to be re-input.

5. If the exam was requested, the status of the exam will be shown.

6. To reprint the completed exam, choose option 7 (RO reports menu), then choose option 2.

 

 

C. Requesting 7131 Hospital information

 

1. From main menu, select 1 for inpatient information, 2 for outpatient.

2. Enter first letter of last name and last 4 digits of SSN.

3. A display of all inpatient or outpatient information will be displayed.

4. Enter the number of the summaries you need.

5. Enter Y for new request or 5 for special report

6. Enter routing location.

 

D. Checking on previous 7131 requests.

 

1. From main menu, select option 3.

2. Enter first letter of last name and last 4 digits of SSN.

3. If it shows finalized, this means the request has been completed.

 

 Appendix A

Sample Letters

1. Request for Report of Investigation A-1

2. Asbestos Exposure Development A-2

3. Mustard Gas Delay Letter A-3

4. PTSD Development - Non-Combat A-4

5. PTSD Development - Combat A-5

6. Alcohol/Drugs Delay Letter A-6

7. Smoking Delay Letter A-7

8. PGW/Environmental Hazards Claim A-8

9. Persian Gulf Registry A-9

10. Request to Social Security for Medical Records A-10

11. General S/C Development A-11

 

Sample Letter 1

REQUEST FOR REPORT OF INVESTIGATION

[Enter First and Last Name of Veteran] has filed a claim for U.S. Department of Veterans Affairs (VA) benefits for disabilities incurred in an incident on [Enter Month, Day and Year of Incident]. We need a report of your investigation in order to process the claim.

The following information may be of assistance to you in locating your investigation report.

  

1. Type of incident: [Enter Type of Incident]

2. Place where incident occurred: [Enter Place Where Incident Occurred]

 

3. Time of incident: [Enter Time of Incident]

4. Veteran's home address: [Enter Veteran's Home Address]

5. Veteran's Social Security Number: [Enter Veteran's SSN]

Please send us a copy of the report of the investigation. The enclosed postage paid envelope may be used for your response.

Your assistance in providing your investigation report will be greatly appreciated.

  

Sample Letter 2

ASBESTOS EXPOSURE DEVELOPMENT

We need additional evidence to process your claim for service connection for asbestos exposure.

On the enclosed VA Form 21-4138, please provide the nature of the disability you have that you feel is a residual of asbestos exposure.

Also, please provide a history of asbestos exposure before, during, and after military service. This should include how you were exposed, location and dates of exposure, and types of jobs in which you were employed during exposure. You should also show a history of all employment since discharge from military service.

This evidence should be submitted as soon as possible, preferably within 60 days from the date of this letter. If the requested information is not received in this office within one year of the date of this letter, benefits to which entitlement is established may not be paid for any period prior to the date of its receipt.

  

Sample Letter 3

MUSTARD GAS DELAY LETTER

We received your claim for benefits based on exposure to mustard gas or other vesicant (blister-producing) agents. However, no further action can be taken on your claim at this time.

On July 31, 1992, the Department of Veterans Affairs (VA) published regulations adding Section 3.316 to Title 38 of the Code of Federal Regulations. These regulations established presumption of service connection based on mustard gas exposure if a veteran was subjected to full-body exposure during field or chamber experiments to test protective clothing or equipment during WW II, and subsequently developed a chronic form of laryngitis, bronchitis, emphysema, asthma, conjunctivitis, keratitis, or corneal opacities.

On January 6, 1993, the National Academy of Sciences (NAS) released a study on the effect of exposure to mustard gas and other vesicant agents. After reviewing these findings, the Department of Veterans Affairs is considering various changes to the current regulations.

 

If we are unable to allow a claim under the current regulations, we will defer processing until changes currently under consideration have been made. We will make our decision concerning your claimed disability as soon as possible after these changes are effective, and we will notify you in writing whether your claim can be approved.

If you have new evidence to submit in support of your claim, you should send it to this office now. Otherwise, there is nothing more you need to do at this time. Please feel free to call our toll-free number (800) 827-1000 or 437-5007 for local calls, if you have questions about your claim or this letter.

 

Sample Letter 4

PTSD DEVELOPMENT - NON COMBAT

We need additional evidence to process your claim for service connection for post-traumatic stress disorder.

Please state the traumatic incident which you believe resulted in post-traumatic stress disorder. You should also state the date(s) and place(s) the incident(s) occurred. If a police report was appropriate or necessary, state the law enforcement agency or other investigative body to which the report was made. You should also provide the identification of the military unit to which you were assigned at the time. Please use the enclosed VA Form 21-4138 for your statement. If the incident was reported to other than a law enforcement or investigative agency such as a counselor, therapist, or clergyman, please complete the enclosed release form, VA Form 21-4142.

This information is necessary to obtain supportive evidence of the stressful event(s); if we do not receive a response, it may make it impossible to obtain such evidence.

You can call us toll free by dialing 1-800-827-1000. If you are hearing impaired and must communicate through a Telecommunication Device for the Deaf (TDD), our TDD number is 1-800-829-4833.

This evidence should be submitted as soon as possible, preferably within 60 days. If it is not received in this office within one year from the date of this letter, benefits to which entitlement is established may not be paid for any period prior to the date of its receipt.

If you would like information about counseling, please contact your nearest Veteran Center or VA Medical Center.

 

Sample Letter 5

PTSD DEVELOPMENT - COMBAT

We need additional evidence to process your claim for service connection for post-traumatic stress disorder.

Please furnish a detailed description of the specific traumatic incident(s) which produced the stress that resulted in your claimed post-traumatic stress disorder, including dates and places the incident(s) occurred, the unit (division, regiment, battalion, company) to which you were assigned or attached at the time, medal(s) or citation(s) received as a result of the event(s), and name(s) and other identifying information concerning any other individuals involved in the event(s). If the incident(s) involved the death of one or more friends, furnish their names.

This information is necessary to obtain supportive evidence of the stressful event(s); failure to respond may make it impossible to obtain such evidence.

You can call us toll free by dialing 1-800-827-1000. If you are located in the local dialing area of a VA regional office, you can also call us by dialing

437-5001. If you are hearing impaired and must communicate through a Telecommunication Device for the Deaf (TDD), our TDD number is

1-800-829-4833.

This evidence should be submitted as soon as possible, preferably within 60 days. If it is not received in this office within one year from the date of this letter, benefits to which entitlement is established may not be paid for any period prior to the date of its receipt.

 

Sample Letter 6

ALCOHOL/DRUGS DELAY LETTER

We cannot approve or deny your claim for benefits based on conditions which are secondary to the use of alcohol or drugs.

Effective November 1, 1990, PL 101-508 prohibits the granting of service connection for secondary conditions of alcohol or drug use.

A final determination on your claim will be delayed until we receive approval of final regulations covering your claimed disability. We will notify you as soon as we can make a decision on your claim.

There is nothing more you need to do at this time. However, please feel free to contact this office if you have questions about your claim or this letter.

 

Sample Letter 7

 SMOKING DELAY LETTER

We have received your claim for Department of Veterans Affairs (VA) benefits; however, we are unable to process your claim for service connection for the remote effects of smoking or for the remote effects of secondary smoke at this time.

General Counsel has determined that service connection may be established for the remote effects of smoking, and that nicotine dependence may qualify as a disease entity. Currently, VA is requesting guidance from the under Secretary for Health concerning medical aspects of nicotine dependence and tobacco-related disease. Therefore, adjudication of these claims has been suspended pending further instructions.

 

We have placed your case under a control being maintained by this office for immediate review upon implementation of the new regulatory guidelines. There is nothing more you need to do at this time. However, if you have any further questions concerning this matter, please contact your local Regional Office by calling our toll-free number, 1-800-827-1000. A Veterans Benefits Counselor will be pleased to assist you.

 

 Sample Letter 8

 PGW/ENVIRNONMENTAL HAZARDS CLAIM

 This letter is to acknowledge receipt of your claim for benefits based on (Disabilitv/Death) resulting from exposure to environmental hazards during military service in the Persian Gulf.

As part of its program to monitor the possible health effects of exposure to environmental agents in the Persian Gulf, the Department of Veterans Affairs (VA) has designated its regional office in Louisville, KY, as the office to process these claims. Accordingly, we have transferred your records there. That office will advise you further about your claim as it becomes necessary.

You may direct any correspondence or evidence concerning your claim to the VA Regional Office, 545 South Third Street, Louisville, KY 40202. Please be sure to include your VA claim number on all correspondence. While the Louisville Regional Office will be responsible for processing your claim, this office remains available to help you if you have questions concerning your claim or veterans benefits, in general.

 

Sample Letter 9

PERSIAN GULF REGISTRY

Public Law 102-584 requires the Department of Veterans Affairs (VA) to establish and maintain a registry of veterans who served in the Persian Gulf War theater of operations during the Persian Gulf War. This registry will be used as a basis for research on the health consequences of military service in the Persian Gulf theater of operations.

If you served in the Persian Gulf theater of operations, your name will be automatically included in the registry. VA will also include relevant medical and other information about you, but we need your permission to do so. The information in the registry will be shared only with the Department of Defense and others as provided by law, for example, the National Academy of Sciences for research purposes.

Periodically, VA will inform you of significant developments in research on the health consequences of military service in the Persian Gulf theater.

If you want relevant medical and other records included in the registry, please sign the enclosed statement, and return it in the enclosed self-addressed envelope. Be sure that you place your return address and the proper amount of postage on the envelope before mailing it. If you do not want your records included in the registry, you do not have to do anything.

 

 

Sample Letter 10

REQUEST TO SOCIAL SECURITY FOR MEDICAL RECORDS

The Department of Veterans Affairs (VA) has received a claim for benefits from the person named below, and we need to establish his/her unemployability status.

Please provide us with copies of all Social Security Administration decisions, to include Administrative Law Judge decisions, as well as copies of all supporting medical records used in making those decisions.

NAME AND ADDRESS OF CLAIMANT:

NAME OF WAGE EARNER:

WAGE EARNER'S SOCIAL SECURITY NUMBER:

DATE AND PLACE OF BIRTH OF WAGE EARNER:

Please forward the information as soon as possible, preferably within 60 days, so we can make a determination on his/her claim.

 

Sample Letter 11

GENERAL SERVICE CONNECTION DEVELOPMENT

We have received your claim for service connection for (disability). For your claim to receive favorable consideration, the evidence of record must show that your disability was incurred in or aggravated by your military service, and that it is still disabling.

OPTION 1 On your application, you failed to show dates and places of treatment for your claimed disabilities. Please complete, sign and return the enclosed VA Form

OPTION 2 We have been unable to obtain records of your claimed treatment in service. If such records are in your possession, please send them to us. We shall make copies and return the originals to you.

OPTION 3 Evidence that your disability was incurred in or aggravated by your service may consist of statements from officers or enlisted men or other persons with whom you served. Such statements should contain complete information as to the nature and extent of your disability and include how, when, and where the disability was incurred or aggravated. Each statement from a service comrade should include his former rank, organization, and service number, or other information showing when and where he served with you.

OPTION 4 Evidence that your disability has continued since your discharge from service may consist of statements from doctors or other persons who have knowledge of your condition subsequent to your discharge. These statements should include the date they first observed your condition, just what they observed, and their relationship or association with you which enabled them to make this observation. when taken as a whole, these statements must clearly show that your disability has persisted continuously since your discharge from service.

 

OPTION 5 The best evidence that your disability still exists would be the statement of a doctor who has recently treated or examined you. Such statement must give the exact date of treatment or examination, complete findings and diagnosis. Also, statements of your employers, friends , neighbors, and relatives, who can state facts of their personal knowledge, which show that your disability still exists, would be acceptable.

All statements submitted must bear a certification above the signature of the maker reading substantially as follows:

"I hereby certify that this information is true and correct to the best of my knowledge and belief."