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The United States provides a wide range of benefits for veterans with Posttraumatic stress disorder (PTSD), which was incurred in, or aggravated by, their military service. The United States Department of Veterans Affairs (VA) will provide benefits to almost all veterans that the VA has determined suffer from PTSD, which developed during, or as a result of, their military service, and which interferes at least to some extent in their ability to work. These benefits not only include tax-free cash payments but can also include free or low-cost mental health treatment and other healthcare; vocational rehabilitation services; employment assistance; independent living support; and more.
VA disability benefits for PTSD have evolved over time, in response to legislation, scientific advances, political pressure, revised diagnostic classification schemes, regulatory changes, case law, and administrative decisions. Veterans advocacy organizations, researchers, clinicians, politicians, administrators, and citizens will no doubt continue to influence how the United States evaluates, adjudicates, and administers the program. For example, current efforts at change or reform include urging the VA to place more emphasis on vocational rehabilitation and treatment versus cash payments; revising the Rating Formula for Mental Disorders to better reflect problems experienced by veterans with PTSD; establishing a balance between efforts to decrease claims processing time (productivity) with the need for consistency and accuracy of examination results and rating decisions (quality); and considering a veteran's quality of life as a factor in determining the disability rating.
Since the founding of the country, the United States has sought to compensate the men and women who have served in its armed forces. Initially this compensation was given to all veterans as a gratuity payment, i.e., as a 'thank you' for their service. But in 1917, the U.S. Congress initiated a shift in the rationale for compensation away from a gratuity system and toward an indemnity scheme. Since that year, compensation has been provided to veterans suffering from physical or mental disabilities that were incurred during, or aggravated by, military service, and which have adversely impacted the veteran's ability to work. The amount of compensation provided—both cash payments and VA-sponsored services—are based on the veteran's average impairment in earnings capacity.
This section provides a brief overview of the 8-step claims process; describes how a veteran files an initial claim for PTSD disability benefits; how and why to ask for assistance with filing a claim; and how to locate and select sources for such assistance.
The VA provides a description of the 8-step benefits claims process on its website. This is a brief overview:
1. Claim Received - The veteran has submitted a disability compensation claim in person (e.g., while still on active duty with a VBA (Veterans Benefits Administration) representative visiting his or her base), online (via the Veterans On-Line Application [VONAPP]), or by postal mail to the VBA Regional Office (VARO) assigned to his or her geographical location (legal residence). The VARO sends a letter to the veteran via postal mail confirming receipt of the claim.
2. Under Review - A VSR (Veterans Service Representative ) reviews the information submitted by the veteran to determine if VBA needs any additional evidence (e.g., service medical records) to adjudicate the claim.
3. Gathering of Evidence - VA has a legal obligation to help veterans obtain any evidence that will support their claim. For example, the VSR might request a veteran's military personnel records (e.g., to confirm unit assignments), Social Security disability records (if the veteran applied for Social Security disability benefits), or private medical records. The veteran can also obtain such records and submit them to the VBA Regional Office handling his or her claim. If necessary, the VSR will request a Compensation and Pension examination (C&P exam) at this time.
4. Review of Evidence - An RVSR (Ratings Veterans Service Representative) makes sure that all relevant evidence has been obtained, and, if so, renders a decision regarding the veteran's claim. The RVSR refers in part to the General Rating Formula for Mental Disorders when making this determination.
5. Preparation for Decision - It is not clear how this step differs from the previous step. The exact quote from the VA website is: "The Veterans Service Representative [presumably they mean the Ratings Veterans Service Representative] has recommended a decision, and is preparing required documents detailing that decision. If more evidence is required, the claim will be sent back in the process for more information or evidence."
6. Pending Decision Approval - Approval by a supervisor.
7. Preparation for Notification - Preparing the "claim decision packet" (Decision Letter and explanatory materials).
8. Complete - VBA mails the "claim decision packet" to the veteran.
To begin the disability claim process, a veteran must submit an application to the Veterans Benefits Administration (VBA), an organizational element of the VA. The VBA, based on their review of medical and psychological evidence, must conclude that the veteran indeed suffers from service-connected PTSD. Reaching such a determination usually requires that the veteran receive a Compensation and Pension examination (C&P exam), which is a forensic[a] mental health evaluation conducted by a psychologist or psychiatrist at a local VA medical facility or by a psychologist or psychiatrist in independent practice who conducts evaluations for a VA-contracted private vendor.
A veteran can apply for compensation benefits him or herself by filling out VA Form 21-526, Veterans Application for Compensation and/or Pension and mailing it to their local Veterans Benefits Administration Regional Office, often referred to as the "VARO" (VA Regional Office). Note that VA Form 21-526 and the accompanying instructions are quite detailed, which is probably why the VA recommends that veterans take advantage of expert assistance from specially trained Veterans Service Officers (see next section).
A veteran may also file a disability benefits claim online using the Veterans On-Line Application (VONAPP) System.
Veterans may receive assistance with filing a VA disability compensation claim from Veterans Service Officers, also known as "VSO Representatives" or "Veterans Service Representatives",[b] especially when they are affiliated with a nonprofit Veterans Service Organization.
Note in this regard that the VA specifically recommends that veterans ask a Veterans Service Officer to help them file a disability compensation claim. Here is a quote from the VA website, which explains why the VA makes this recommendation:
VA encourages individuals who are applying for disability compensation to work with an accredited representative ... to assist them.... Being accredited means organizations and individuals must have VA permission to represent Veterans before the Department in their claims for VA benefits. The purpose of this requirement is to ensure that Veterans have qualified and competent representation. These individuals receive specialized training in VA benefits law and procedure.
Although at least one prominent veterans advocate recommends that "...veterans file their own claims without the assistance of any sort of representative...except for an appeal" (see Post-Adjudication Representation, below, for information regarding legal representation for appeals).
The next two sections briefly describe the two types of Veterans Service Officers.
County Veterans Service Officers are public employees of their State's (or Territory's) veterans affairs agency. They are often called County Veterans Service Officers, because a majority of the states have set up local veterans affairs offices in each of the state's counties.
Many not-for-profit Veterans Service Organizations recruit, train, and support their own Veterans Service Officers to help veterans file claims and navigate the claims process. In order to represent a veteran before the VA, the Veterans Service Organization must either have been Chartered by the U.S. Congress or have received official approval from the U.S. Department of Veterans Affairs to represent veterans in the disability compensation claims process.
As noted above, these Veterans Service Officers are sometimes called VSO Representatives.
Although to make matters somewhat confusing, the VA sometimes refers to both County Veterans Service Officers and VSO Representatives as "Veterans Service Organizations (VSO) Representatives" or "VSO Representatives." For example, if you conduct an "Accreditation Search" on the VA website and search for a "VSO Representative," the search results will list both County Veterans Service Officers and VSO Representatives.
Veterans may select either type of Veterans Service Officer to help them file their disability compensation claim(s). After the veteran selects his or her Veterans Service Officer, he or she completes VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative and submits it to the Veterans Benefits Administration. (Note that for the purposes of Form 21-22, a State or Territory veterans affairs agency is considered to be a "Veterans Service Organization"). This appointment authorization gives the Veterans Service Officer legal authority to represent the veteran's interest in communications with VBA and any other related agencies or organizations involved in the disability benefits claims process.
After VA Form 21-22 has been received and accepted by the Veterans Benefits Administration, the Veterans Service Officer helps the veteran file the initial disability compensation claim. Subsequent to filing the claim, the Service Officer may also engage in a variety of other, related, activities on behalf of the veteran, for example, calling the Veterans Benefits Administration to inquire about the status of a veteran's claim, or appearing with a veteran when meeting with VBA officials, or helping the veteran understand the Compensation and Pension (C&P) examination process.
The veteran does not pay a Veterans Service Officer for their services. The Service Officers are either state employees, employees of a Veterans Service Organization, or are volunteers for a Veterans Service Organization.
If a veteran is not satisfied with the VBA's decision regarding their compensation claim, they may appeal the decision, and they may ask to be represented by an accredited attorney or claims agent in the appeals process. Veterans usually appeal a decision because their claim was either denied outright or because they believe that the disability rating assigned by the VBA is incorrect.
Note that the VA does not require a veteran to be represented by an attorney or claims agent. In addition, Veterans Service Officers may assist a veteran through the appeals process (although he or she is usually not an attorney so may not be as familiar with legal proceedings, relevant case law, legal strategies, etc.).
VA prohibits attorneys or claims agents from charging a veteran for professional services prior to the adjudication of the veteran's claim. A veteran may contract with an attorney or claims agent to represent them in an appeal only after the following three conditions have been met:
Unless they agree to work on a pro bono basis, attorneys and claims agents who represent veterans before the Veterans Benefits Administration, Board of Veterans Appeals, and Court of Appeals for Veterans Claims require payment for their services. In most instances, the veteran and attorney (or claims agent) submit a signed payment agreement with the VA Office of General Counsel, which stipulates that the attorney will receive payment directly from the VA after the veteran's claim has been adjudicated, if the adjudicator awards service-connected disability compensation to the veteran. The amount of the attorney's fee is based on a percentage of the lump sum "back pay" compensation issued to the veteran by the VA.
Attorneys who wish to represent veterans in proceedings before the agency of original jurisdiction (the Veterans Benefits Administration), the Board of Veterans Appeals, or the Court of Appeals for Veterans Claims, must first receive accreditation from the VA General Counsel. The attorney begins the process by submitting an Application for Accreditation as a Claims Agent or Attorney (VA Form 21a).
Accredited claims agents must submit an application to the VA General Counsel, which includes submitting the names and contact information of three character references; pass a written examination; and complete three hours of qualifying continuing legal education (CLE) within 12 months of their initial accreditation.
If an RSVR determines that a veteran indeed suffers from service-connected PTSD, then he or she assigns a disability rating, expressed as a percentage. This disability rating determines the amount of compensation and other disability benefits the VA will give to the veteran. The disability rating indicates the extent to which PTSD has deprived the veteran of his or her average earnings capacity. A rating of 0% means that a veteran has PTSD but the disorder has not affected his or her ability to work, whereas a 100% rating indicates that the veteran is not capable of working at all because of PTSD.
The VA assigns disability ratings for PTSD according to the General Rating Formula for Mental Disorders (38 C.F.R. §4.130), which specifies criteria for disability ratings of 0%, 10%, 30%, 50%, 70%, or 100%.
Some argue that by relying on the current Rating Formula, "VA uses decades-old regulations developed for mental disorders that do not resemble PTSD", and, consequently, "[i]rrelevant criteria ... may outweigh ... more relevant factors, leading VA to undercompensate veterans with valid diagnoses of PTSD." Similarly, veterans service organizations have argued, for example, that a "...veteran service connected for schizophrenia and another veteran service connected for another psychiatric disorder should not be evaluated using the same general formula" and have supported efforts to revise the Rating Formula.
A veteran currently receiving compensation for service-connected PTSD may request in increase in his or her disability rating (the VA also refers to this as an increased disability evaluation, although increased disability rating is more common) for one of three reasons: 1) Perceived error; 2) Worsening symptoms and functioning; or 3) Individual unemployability.
A veteran must present new evidence in order to request an increase in his or her disability rating. This new evidence almost always takes the form of greater symptom severity and functional impairment and/or individual unemployability. Since the veteran's lay testimony (self-report) is generally accepted for such purposes, it is usually not difficult for a veteran to request an increase in his or her disability rating.[c]
A veteran may request an increased rating if he or she believes that their initial rating was in error, i.e., it was not high enough. If a veteran requests an increased rating for this reason within the first year after the rating decision, it is considered to be an appeal of the VBA's rating decision. If a Veteran does not appeal the initial rating decision within one year, then he or she technically must request an increased rating due to worsening symptoms and a deterioration in functioning, even if their "real" reason is because they believe the initial rating decision was a mistake.
As noted above, if a veteran believes that his or her condition has worsened, he or she may request an increased disability rating.
If a veteran believes that PTSD, either or alone or in combination with other service-connected disabilities (e.g., diabetes, a back injury, chronic pain, etc.), renders him or her incapable of pursuing and retaining gainful employment, and he or she meets the eligibility requirements, then he or she may file a compensation claim based on unemployability using VA Form 21-8940.
Dr. Matthew J. Friedman of the National Center for PTSD notes that:
PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an historical event that is considered traumatic.
A traumatic stressor is an event that meets Criterion A of the DSM-IV diagnostic criteria for PTSD. Criterion A reads as follows:
The person has been exposed to a traumatic event in which both of the following have been present:
A1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.A2. The person's response involved intense fear,helplessness, or horror.
Note that Criterion A2 was removed for DSM-5, and the wording of Criterion A was changed as follows:
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
The VA transitioned to using DSM-5 for clinical (treatment) purposes on 1 November 2013, and for forenisic (C&P examination) purposes on 1 December 2013. However, the regulations governing PTSD disability compensation specifically reference DSM-IV and those regulations have not yet been updated. Therefore, VA has instructed C&P examiners to first determine if a Veteran meets DSM-5 criteria for a PTSD diagnosis, and, if not, to then determine if he or she meets DSM-IV diagnostic criteria for PTSD. Presumably, veterans will be considered service-connected for PTSD if either set of criteria are met, although this is a new area of veterans law so firm conclusions cannot yet be made.
The term, service-connected, means that a veteran has a disease or injury that is "connected" to his or her military service, i.e., the disease or injury was incurred in, or aggravated by, his or her military service.
The official definition in the Code of Federal Regulations begins:
Service connection connotes many factors but basically it means that the facts, shown by 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 therein.
The relationship between service connection and access to VA healthcare is emphasized in this definition:
"'Service connected' veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system."
There are four types of service connection: direct, secondary, aggravated, and presumptive. The present article is primarily concerned with direct service connection, since that is by far the most common type for soldiers, sailors, marines, airmen, or coast guardsmen suffering from PTSD.
As noted, the vast majority of veterans with PTSD have a direct service-connection, i.e., they developed PTSD as a direct result of a traumatic stressor (or stressors) they endured during their military service. Traumatic stressors can be:
These are the most common situations involving traumatic stressors that can lead to direct service connection for PTSD, but it is not an exhaustive list.
Also, note that a service member is still considered to be enrolled in military service even if he or she is not performing specific military duties at the time they are injured (e.g., if they are injured at their home on their day off, that injury, if it results in a permanent disability, would in most instances be considered service-connected).
The regulations describe three categories of military service, active duty, active duty for training, and inactive duty training. These categories and their very specific definitions would be particularly relevant to a veteran who, for example, experienced a traumatic stressor that led to PTSD during a period of training for the Reserves or National Guard.
And there are some types of military service which are defined as falling under one of the three categories that might not occur to many people, such as the fact that the definition of active duty military service includes "service at any time as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy." - 38 CFR § 3.6(b)(4). Thus, a midshipman who was sexually assaulted and developed PTSD would, when he or she left the Navy, qualify for VA benefits.
And there are other specifications in this set of regulations (38 CFR § 3.6) that one would never anticipate, such as the fact that the definition of active duty for training includes National Guard soldiers who participated in the reenactment of the Battle of First Manassas in July 1961 (38 CFR § 3.6(c) (3)).
"In line of duty means an injury or disease incurred or aggravated during a period of active military, naval, or air service unless such injury or disease was the result of the veteran’s own willful misconduct or ... was a result of his or her abuse of alcohol or drugs." The most important point here is that there are exceptions to the general rule that injuries or diseases incurred in, or aggravated by, military service are eligible for disability compensation benefits. Veterans who have questions about eligibility for VA benefits because of willful misconduct, alcohol or other drug abuse, or discharge status (see the next section), or other factors (see the regulation referenced above), can consult with a Veterans Service Officer in their area and/or contact the VBA Regional Office closest to their home for assistance.
In order to be eligible for VA benefits, a veteran must have been discharged under other than dishonorable conditions. Stated differently, if a veteran received a Bad Conduct Discharge or a Dishonorable Discharge they will, under most circumstances, not be eligible for VA benefits.