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Top 5 VA Mental Health Claim Mistakes

Top 5 VA Mental Health Claim Mistakes

Video Transcription

Kayla D’Onofrio: Welcome to CCK Live. My name is Kayla D’Onofrio. I’m an accredited claims agent here with the agency practice at the firm. I’m joined today by Frank Padula and Matthew Fusco who are also accredited claims agents working in the agency practice.

Today, we are going to be reviewing some of the biggest mistakes that veterans make when they’re filing VA mental health claims. As just a sort of general overview of VA ratings for mental health, veterans can receive disability compensation for physical and mental health conditions that are caused by their military service.

VA rates mental health conditions differently obviously than physical ailments, and not all psychiatric disorders qualify for service-connected disability compensation, for example, personality disorders will not qualify. Today, we’re just going to be focusing on those disorders that would qualify for compensation and the types of claims, and how to go about doing so.

Just some examples of some eligible mental health conditions would include things like anxiety or panic disorders, trauma and stressor-related disorders like PTSD, psychotic disorders like schizophrenia, cognitive disorders like ADD or ADHD, eating disorders such as anorexia or bulimia, mood disorders such as major depressive disorder, or residual psychiatric effects from traumatic brain injuries or TBIs.

Aside from eating disorders, VA rates all mental health conditions using the same diagnostic criteria. Those conditions are going to be rated at either a 0%, 10%, 30%, 50%, 70%, or 100% rating using VAs general rating formula for mental disorders. These ratings are based on the level of social and occupational impairment caused by service-connected mental health conditions. Meaning how that condition affects your ability to interact with other people and your ability to work.

Just one thing that we want to note is that VA has recently proposed to change the way that they rate mental health conditions. As of right now, it is still just a proposal, nothing is finalized. But we do have some other videos on our website that talk a little bit more in-depth about those proposed changes and how they can affect veterans who are going through the claims process, specifically for mental health conditions.

Once you determine that you have a mental health condition and you think it’s related to service, the next thing that you’re going to want to do is file a claim. Matt, what are some common mistakes that veterans might make when filing claims, and what can they do to avoid them?

Matthew Fusco: One of the more common mistakes we see being made in filing claims for mental health conditions is not submitting all the necessary forms that VA requires. Generally, veterans should download and fill out a VA Form 21-526EZ when they’re applying for, specifically, the benefits and mental health benefits, as we’re discussing. This can be submitted via mail to the claims intake center, in person at your closest VA regional office, or even electronically through VA’s website.

It’s important to note here that if your claim for a mental health condition was previously denied and you’re outside of the one-year mark needed to appeal that decision, you’re going to need to file a supplemental claim, which requires a different form than this initial claim form that we’re discussing. We have some other videos posted to our website that get into the specifics of supplemental claims and filing supplemental claims, but that’s just something that we felt was important to note here.

If you are specifically seeking PTSD benefits, VA requires that you fill out some additional forms. You’re going to want to submit either a VA form 21-0781, which is a statement in support of a claim for service connection for post-traumatic stress disorder, or a VA form 21-0781A, which is a statement in support of a claim for service connection for post-traumatic stress disorder, secondary to a personal assault. Those are some additional forms you’ll need to fill out if you’re specifically seeking PTSD benefits as a part of your mental health claim.

Kayla: I think something important to note with those specific forms is that they’re asking for information about what your stressor is, details about your stressor, what happened when it occurred, where you were stationed, or where you were located when it occurred.

You can also submit that statement just using general lay evidence without the forms. But in order to make sure that VA has all the information, especially if you don’t have a representative, the form is probably your best option to make sure you have all the information that VA is looking for.

If you have more than one mental health condition, Frank, how should you go about filing for those and what is VA going to do with all of the different diagnoses?

Frank Padula: When you submit a claim for a particular mental health condition, VA should process your claim as a claim for any mental health condition. This means that VA is not supposed to limit its consideration to the particular mental disorder identified on your claim form. It may be beneficial to keep your claim in a more broad sense and claim any mental health condition.

Additionally, veterans with more than one mental health condition should be aware of pyramiding. Pyramiding is the VA term for rating the same disability or manifestation or symptom of a disability twice. For example, veterans who suffer from PTSD might also have a diagnosis of major depressive disorder.

If VA has conceded that both of these conditions are attributed to the veteran’s service, the veteran is not going to receive a rating for PTSD and a rating for major depressive disorder. Instead, the veteran may receive a combined rating under the diagnostic code for only one of those conditions. Overall, VA does not consider the number of mental health disorders, but instead the severity and impact of each in order to assign a single comprehensive rating.

Kayla: Great. Thank you. When you are looking for VA to decide on your claim, the other thing that they’re looking at the outside of just what you submit is the evidence that’s included. One common mistake that we see happen both on the veteran and VA’s end is relying solely on C&P or Compensation and Pension exams. The problem with that is that Compensation and Pension exams are often not an adequate picture of the true nature or extent of the veteran’s conditions.

Instead, there are other things that we want to do to maybe supplement the record, especially when it’s not the most comprehensive or it is a negative opinion. Expert opinions or nexus letters can be particularly helpful in these circumstances. They can provide a much clearer picture of the veteran’s symptoms and counter any negative VA examiner findings. The veteran’s physician or medical provider can provide a nexus letter as long as they’re a qualified expert in the area where you’re seeking benefits.

For example, a psychologist or a psychiatrist for mental health claims. If you have an accredited representative or an attorney that represents you, they may also be able to obtain an expert medical opinion through an expert that they may work with to serve as a nexus letter. They would be responsible for looking through your claims file in its entirety and in some circumstances, conducting an interview with you if they would need it to supplement the record.

You can also get additional medical evidence within the file. If you do treat for a mental health condition, especially if it’s outside of a VA through a private treating physician, adding those records to your claims file can be particularly helpful for compensation and pension examiners to look at and for VA adjudicators to look at when they’re making a claim. They can provide a lot more context to your disability, including the onset and the severity of those symptoms.

In addition, you can also have your treating physician fill out a Disability Benefits Questionnaire form or a DBQ form. This form is essentially the same set of questions that VA examiners are filling out when they’re conducting those exams.

It allows veterans or their health care provider to answer questions about different aspects of their disability including their symptoms, the severity of their symptoms, the onset or possible cause of their symptoms, as well as any relation to any other service-connected disabilities if that’s applicable in the case.

Matt, is there any other evidence that might be helpful for these types of claims?

Matthew: Sure. Something we wanted to discuss and suggest is submitting lay evidence in your case. So, veterans will often think that their medical records alone are sufficient to win disability benefits. However, in our experience, this is not always the case. Mental health conditions, specifically, can be really difficult to quantify. And medical records alone may not be able to capture the full scope of a disability and how it impacts a veteran’s day-to-day life. Along those lines, it’s important and we want to underscore that veterans should submit written statements describing how their mental health condition impacts their day-to-day functioning in their everyday life.

Another type of lay statement that you can consider submitting is statements from family members, friends, or co-workers with whom you may spend a portion of your time. These accounts can help to corroborate your statements and paint a fuller picture of your condition in the way that it affects you and others around you. However, it’s important to know that submitting too much evidence that is not particularly relevant to your claim can make it difficult for VA to sift through that information and locate the pertinent evidence that is most relevant to the condition you’re claiming.

Along those same lines, it’s important to ensure consistency in the lay evidence that you are submitting in your case to make sure that the evidence you are submitting is following the same kind of timeline, story, and symptoms being reported that you’ve submitted along the life of your claim.

So, that’s another thing that veterans want to make sure that they are doing is ensuring consistency to avoid any negative credibility findings from the VA.

Kayla: That’s a really good point. Thanks, Matt. So, with the different rating criteria, VA kind of outlines the social and occupational impairment, and they also list a number of symptoms that might be associated with a particular rating. Frank, does a veteran need to have every symptom that’s listed in the rating criteria to get that particular rating or what should they do in order to prove the severity?

Frank: It’s important to understand that veterans do not need to exhibit every single symptom listed in the rating criteria to receive that particular disability evaluation. Since mental health conditions can manifest differently per individual, VA’s rating formula for mental health conditions is not binding.

And symptoms listed in each level of the rating formula are simply examples meant to demonstrate the types and levels of impairment commonly found at that assigned percentage rating.

Kayla: If you’re not happy with the rating that they assign or if they just deny your claim for service connection, what options do you have?

Frank: It’s also important to understand that veterans have the right to appeal unfavorable decisions from VA. In other words, if your mental health claim is denied or you receive a disability rating that is lower than you deserve, you can disagree with VA’s decision and continue to seek service connection or that increased rating.

For instance, when a veteran files an initial claim, VA might grant service connection but assign a lower rating than you want. And instead of filing a new claim for an increased rating, it is more beneficial to file an appeal for that increased rating.

And under the new VA appeal system, veterans can choose from three different review options or lanes when filing an appeal. The first being the Higher-Level Review lane, the second being the Supplemental Claim lane, and the third is the Notice of Disagreement lane, otherwise known as an appeal to the Board of Veterans’ Appeals.

And continuing to pursue a claim through the appeals process allows veterans to preserve their effective date and could entitle them to a larger sum of retroactive benefits down the road.

Kayla: Great. And one important thing to note is those different appeal options, some are applicable to certain decisions while others are not. And the different appeal options do have sort of different rules for when you can or can’t submit evidence and what VA is going to consider.

We have a lot of other videos dedicated to this specific topic on our website and our other social. I do recommend checking those out for more information about the different appeal options and sort of the rules that go along with each of them.

But with that, I think that’s a good place for us to close out today. Matt or Frank, do you have any sort of closing thoughts or any other things you want veterans to keep in mind when filing these types of claims?

Matt: Just I guess, one tip that you kind of mentioned earlier, Kayla, is seeking the help of an accredited representative can be a really useful tool when it comes to this type of thing to avoid mistakes in the claims filing process, especially for mental health claims because they can get a bit complicated as with many other things with filing VA claims.

I think that one thing we would suggest is that seeking out the help of an accredited representative or attorney can be super useful to avoid any pitfalls in the claims process.

Kayla: Great.

Frank: Yeah. I have to second what Matt says. It can be very complicated with these types of claims. So, if you need help at all, I would seek out an accredited representative or attorney to help you out.

Kayla: Agree. Thank you both so much. Thank you all for tuning in today. Be sure to subscribe to our channel, and check out our library of videos for more information about the VA claims process.