Evidence VA Looks for in Disability Claims

CCK Law: Our Vital Role in Veterans Law

Building a winning veterans disability claim requires more than just completing paperwork. It demands a careful assembly of strong evidence. Veterans must provide compelling proof that their disabilities are connected to military service or that their service-connected conditions have worsened over time.

The Department of Veterans Affairs (VA) will consider a veteran’s military records, medical records, personal statements, and other evidence when deciding whether to grant such benefits. Before filing a VA disability compensation claim, veterans should understand the types of evidence VA considers when reviewing a claim.

In this article, CCK Law will discuss:

• Establishing service connection
• VA’s standard of proof
• Key types of evidence for VA claims
• Special evidence considerations veterans should know

Veterans may also use the CCK VA Claim Builder tool to identify the types of evidence most relevant to them.

Legal Considerations Regarding Evidence

What Veterans Must Prove

The evidence a VA claim will need depends on the type of claim the veteran is filing. In most claims for VA disability compensation, veterans need to prove three core elements that establish service connection:

• A current, diagnosed disability: Veterans must present proof that they have a formal medical diagnosis of the condition for which they are claiming benefits.
• An in-service event, injury, or illness: Veterans must also show evidence of something happening during their service—whether it’s an injury, event, or illness—that could have led to their current disability.
• A nexus (i.e., link) between the disability and service: There must be medical evidence that links the in-service event to the diagnosed disability. A nexus letter from a qualified medical provider can serve as a persuasive medical opinion.

If any of these elements are missing, then VA will likely deny the claim. Gathering the right evidence that clearly addresses all three requirements is crucial.

For increased rating claims, the focus shifts. Veterans must prove that their existing, service-connected disability has worsened and now meets a higher percentage under VA’s rating schedule.

VA’s Standard of Proof

When establishing service connection, veterans must meet a unique legal standard: their condition must be “at least as likely as not” related to military service—in other words, a 50/50 chance. If the evidence is evenly balanced for and against the claim, VA is required to decide in the veteran’s favor. This is considered a favorable standard for veterans.

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However, evidence must still be persuasive, consistent, and credible. Submitting clear medical records, strong lay statements, and expert opinions can help ensure that VA resolves any doubt in the veteran’s favor.

VA’s Duty to Assist

The VA initial claims process is supposed to be non-adversarial. As a result, VA has a legal duty to assist veterans with identifying relevant claims and collecting evidence during initial claims and supplemental claims. As long as VA is aware that they exist, VA has a duty to make a reasonable effort to help the veteran do tasks like:

• Obtain medical records
• Schedule compensation and pension (C&P) exams
• Notify veterans of additional evidence needed to support their claims

Key Types of Evidence for VA Claims

A successful VA claim often hinges on a combination of military, medical, lay, and employment evidence. Medical opinions and official records often hold more weight for VA than lay evidence, but all play a role in the strengthening of a claim. Therefore, each of these categories of evidence will be explained below.

Military Service Records

Military records serve as the foundation for many disability claims. These records can show an event or the onset of symptoms during service. Common and useful types of service records that can be used include:

• DD214 (Certificate of Discharge): This is a separation document that service members receive when they are discharged from service. It shows a veteran’s discharge status, which VA uses to determine eligibility for benefits. DD214 may also list the locations in which a veteran served.
• Service Medical Records (SMRs): These records show healthcare visits during active duty. This can include sick call visits, hospitalizations, physical exams, and notations of symptoms or injuries. SMRs are critical for showing that a condition either started during service or that symptoms first appeared while the veteran was still in service.
• Personnel Records: Service personnel files contain evaluations and performance reviews. These records can help show that a veteran’s ability to perform their duties was affected. For example, it would show missed duties or job transfers that could support certain claims.

Veterans can obtain these records in a few ways. A veteran can choose to request the records from their VA Regional Office. They can also submit Standard Form (SF) 180 to obtain any relevant records.

In some cases, veterans may also wish to submit a Freedom of Information Act (FOIA) request, or Privacy Act request, to obtain their records. For example, submitting a FOIA request can be useful if a veteran is trying to obtain Navy Deck Logs in support of their claim.

Medical Evidence

Establishing a current, diagnosed disability requires gathering medical evidence. If a veteran is seeking an increased rating, medical evidence can also prove that a veteran’s condition has worsened. Some of the most common types of medical evidence veterans often submit as part of their claims include:

• In-Service Medical Records: These records include enlistment and separation examinations, as well as any hospital stays during service. These records can demonstrate that a condition was noted in service or shortly thereafter.
• VA Medical Records: Treatment records from VA medical centers or clinics are available to VA during claims processing. These records show ongoing care, diagnoses, and changes in a veteran’s health over time. If a veteran wants to obtain these records, they can request them directly from the VA medical center.
• Private Medical Records: VA recognizes that care provided outside the VA system can help fill out the full picture of a veteran’s condition. Veterans can submit these records themselves or sign a release for VA to request them.
• Compensation and Pension (C&P) Exams: In many cases, VA will schedule a veteran for a C&P exam to assess the merits of a service connection or an increased rating for the veteran’s condition.
• Medical Opinions: Veterans can request a medical opinion from their treating doctor to help substantiate their claim. Medical opinions can come in handy if the veteran had an unfavorable C&P examination and wants to argue against the examiner’s findings.

Lay Evidence (Personal Statements)

Lay evidence is a written statement. It can be written by a veteran, family member, friend, or co-worker. These statements can be submitted directly to VA in support of a veteran’s claim. Lay evidence provides firsthand accounts of a veteran’s symptoms, functional impairments, and in-service events when other documentation is missing or incomplete. Each statement should be specific and detailed, and describe how the writer knows the information they are providing. Statements use Form VA 21-10210, “Lay/Witness Statement.”

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Buddy statements (i.e., statements from fellow service members) can corroborate an in-service incident, injury, or exposure. A buddy statement might, for example, confirm that the veteran fell during training or was exposed to hazardous materials, even if there is no formal incident report.

However, contradictions between statements or with the medical record can raise credibility concerns. Veterans should review all statements for consistency before submission.

Employment Records

Employment records are crucial when a veteran is seeking entitlement to the VA disability of Total Disability Based on Individual Unemployability, or TDIU. It compensates veterans at the 100% rating if they have a service-connected disability that prevents them from working, even if they are not rated at 100 percent. Veterans applying for TDIU generally must meet certain rating thresholds or show that their service-connected disabilities uniquely impair employability.

Employment records can significantly strengthen increased rating claims, too. Employment records can indicate that a veteran was having difficulty performing a job or had to receive special accommodations at work due to their service-connected disability.

Examples of employment records veterans can submit to VA include:

• VA Form 21-4192 (Request for Employment Information): VA uses these forms to gather information regarding a veteran’s past or current employment. These forms are sent to the employer, who fills them out with basic employment information. This information can include employment dates and details concerning the veteran’s ability to perform the duties of their job.
• Performance Evaluations: Reviews that document declining performance due to health issues can support claims that a disability impacts occupational functioning.
• Disciplinary Records: Documentation of reprimands, suspensions, or terminations related to disability symptoms, such as anger outbursts, cognitive problems, or absenteeism, can help establish unemployability or the severity of a service-connected condition.

Special Evidence Considerations

PTSD and MST Claims

PTSD claims require proof of a “stressor”—the traumatic event that caused the condition. For combat-related PTSD, a veteran’s own credible lay testimony, along with service records showing combat experience, can be sufficient.

Military Sexual Trauma, or MST, is a specific type of PTSD stressor in which a veteran experienced a physical assault or battery of a sexual nature, or sexual harassment while in service. For these claims, VA acknowledges that assaults are often not officially reported. Thus, veterans can submit indirect evidence, such as:

• Requests for duty station transfers
• Performance reports
• Substance abuse treatment records
• Behavioral health counselling reports

Presumptive Conditions

Presumptive service connection means that VA accepts that certain conditions are related to military service without requiring the veteran to provide a nexus. VA will presume that the veteran’s exposure caused their current condition if they qualify under the presumptions.

Examples include Agent Orange exposure in Vietnam or exposure to environmental hazards during the Gulf War.

However, it is important to note that their condition must be included in VA’s list of presumptive conditions. Eligibility depends on specific dates and locations of service and also whether the veteran’s diagnosis is on VA’s approved list.

Despite not needing to provide a medical nexus for their condition, veterans with presumptive claims must still provide:

• Proof of a current, diagnosed condition
• Proof of qualifying service dates and locations

Emphasis: Many presumptions are related to Vietnam and Gulf War service. But not all Vietnam or Gulf War veterans automatically qualify for presumptive conditions. For example, not all Vietnam-era veterans automatically qualify for Agent Orange presumptions. Likewise, only certain diagnosed and undiagnosed illnesses qualify for Gulf War presumptive service connection.[/cck-ouline-box]

Submitting Evidence to VA

Veterans should submit evidence to VA during their initial claim, but they can submit evidence after VA’s initial decision, too. Once a veteran files a claim, VA will either deny or grant benefits. If VA denies the claim, the veteran will receive a decision letter explaining the reasons for denial. The veteran can use these reasons to determine additional evidence they should submit as part of their appeal to VA.

Having a complete record of evidence is important. When filing an appeal to the Board of Veterans’ Appeals, Veterans should submit all evidence relevant to their claim. If the Board issues a denial, then the veteran cannot submit further evidence to the Court of Appeals for Veterans Claims (CAVC).

Any evidence VA obtains for a veteran’s claim is compiled into the veteran’s “Claims File”—commonly referred to as a veteran’s c-file. In short, a c-file is the total record of the veteran’s case, including all decisions previously made by VA. Veterans can request a copy of their c-file from VA, which can be helpful when preparing an appeal

Further, veterans have several ways to submit evidence to VA:

• VA.gov: Veterans can directly upload documents to active claims via VA’s website. Typically, this is the fastest option for veterans to choose.
• eBenefits Portal: If a veteran has an eBenefits portal, then they can submit evidence there. Veterans should note that VA is phasing out the eBenefits portal and now prefers that veterans submit evidence through VA.gov.
• Mail or Fax: Veterans may still send evidence via traditional methods, such as mail or fax. However, processing times may be slower.

Was Your VA Disability Compensation Claim Denied?

Clearly organized and thoroughly explained evidence can improve the outcome of a VA disability claim. Veterans who proactively gather and submit strong military, medical, lay, and employment evidence strengthen their claims.

But VA may still make mistakes. If VA denies your VA disability compensation claim, then CCK Law may be able to assist. As the nation’s largest and most experienced veterans law firm, we have helped tens of thousands of veterans secure benefits they were wrongfully denied. Call us today at (800) 544-9144 for a free case evaluation with a member of our team.