Developing Supportive Evidence for a VA Claim

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Your disability claim has a lot of moving parts. The process can seem overwhelming with the amount of paperwork and the various systems in place at the VA.

A Veteran’s best chance for success with a claim is to be prepared. Be thorough and gather all your supportive evidence so you can get the rating you medically, legally and ethically qualify for. This is not always easy, but it is well worth your while. Like with all of your claim paperwork, it requires you to be honest, organized, and follow the letter of the law. 

Here are some helpful tips for collecting all the right information and paperwork to support your disability claim. 

1. Know What Your Claim Is Proving 

The supportive evidence you gather will depend on the claim type. There are five different types of VA claims:

  • Rating Increase Claims
  • Direct Claims
  • Secondary Claims
  • Presumptive Claims
  • Aggravation Claims

Increases are the simplest type of claim. With a request for an increased rating, the evidence must pertain to your current disability level as defined in the 38CFR. It is important to include both subjective and objective evidence to support your claim. Subjective evidence is information that is given from your perspective. Objective evidence consists of medical facts and figures, such as an x-ray or medical diagnosis.

Your subjective symptoms and their frequency can be documented in your Lay Statement using VA Form 21-4138.

When gathering objective evidence for your claim, the strongest and most effective evidence will come from a comprehensive medical exam. The doctor should be a specialist in treating your condition or specialize in the field of medicine that covers your condition. Do not ask your VA-affiliated healthcare provider to help you with your disability claim. VA providers are prohibited from doing so since it is a conflict of interest. It is best to find a private specialist who can provide the proper diagnosis of your symptoms.  

2. Don’t Rely on Your Private Provider for Your DBQ

The VA no longer accepts DBQ forms filled out by private medical providers. It’s best to focus on a diagnosis from your private provider, who can document your symptoms, including your pain level, discomfort, and other health issues caused by your condition.

Private providers have been known to scoff or ridicule Veterans asking for a complete exam for disability rating purposes. It is an unfortunate reality that many providers are unaware of VA Disability laws and processes. The provider may mistakenly associate your pursuit of VA disability compensation with Social Security Disability, and might assume you are claiming you cannot work due to your condition to get a free payout – which is far from the truth. Many Veterans have reported harrowing experiences trying to get evidence for their claims with some providers stating, “You don’t need government welfare for this problem, just take the medicine I prescribe for it.” Trying to explain the complexities of the VA Disability system and VA math to a private general practitioner or specialist is likely a waste of your time unless you have a great rapport with your provider.

3. Focus on Getting Proof for Your Symptoms

Focus on the documented symptoms that determine your disability rating. Refer to the 38CFR Schedule of Ratings for your condition to determine which symptoms are important to document.

A simple example is a joint condition. Once you are paid the minimum compensation for a joint’s painful motion, the higher rating is always determined by limitation of range of motion. Ask your provider to document your range of motion without pain. If your movement is limited or restricted due to joint pain, the point you naturally limit your movement on your worst day should be documented. This should be noted as your maximum range of motion. This becomes precious objective evidence for a new claim for increased benefits. 

Be sure to get your provider to evaluate your chronic symptoms during your visit. This is the highest priority. Request the notes from the clinic visit and upload those with your claim. Sometimes, these exam notes will provide the VA raters with all the information they need to increase your rating, and you may even avoid a C&P exam.

If you are requested to attend a C&P exam after submitting this evidence, be sure to bring these exam notes with you to your C&P exam. You can explain to your examiner that you recently had an exam for your condition by your private provider, and you have brought a copy as a reference.

Include Any and All Private Health Care Visits or Information

Any records from non-VA medical providers should be included with your claim. The disability evaluator will have access to all of your VA records, but you must provide private records supporting your claim. These records should include clinic notes, copies of any diagnostic studies, and imaging reports like x-rays or sonograms. You do not need to send the actual images but you will need the imaging report written up by the radiologist. 

If there are multiple reports, be sure to send the one which shows the most degenerative changes. Reading X-ray films can be subjective. One radiologist may interpret an X-ray image as showing “no degenerative changes,” while another may report “mild degenerative changes.” A report of mild degenerative changes can support a diagnosis of arthritis, whereas the other would not. This is important because the VA requires proof of any deterioration, diagnosis, or difficulty.   

For an increased claim, it is best to provide the most recent evidence possible. It is not helpful to send medical reports that are more than a year old. The information should show your most recent health issues and how they have worsened.

After you submit your claim, you may receive a request to complete VA Forms 21-4142 and 21-4142A. These forms are used for the VA to request all the records from your private providers. Although it is fine to do this, you can ignore this request if you have already collected the relevant evidence from your private providers on your own and included the complete records with your claim submission. The VA must decide your case based on the evidence they have after a period of time, even if you do not complete the form. This may make your life easier and expedite the processing of your claim. Waiting for them to obtain your medical records can delay the resolution of your claim. 

4. Don’t Forget Your Conditions Must Be Connected to Active Duty Service

While there may be a few exceptions, your conditions must be service-connected to your time in duty. A new claim for service-connection must include evidence linking your condition to your active duty service. The focus of your supportive evidence will be very different if you are not yet service-connected. Your current disability level is not as important as evidence that connects the dots for the VA. Remember, you must first get the fish in the boat before worrying about its size! You have to connect your disability, or the deterioration of your health, to your active duty for the VA to deem it worthy of your claim.

If it is a direct claim for a condition that started in service and your service records do not contain much evidence, you should provide anything that shows the start of the problem. Proof of persistent chronic symptoms and the earliest treatment or diagnosis are helpful. If your disability resulted from an injury, be sure to include any evidence of the occurrence. This could consist of emails or letters to family or friends, buddy statements from Veterans who served with you, or even news reports of an accident. 

Evidence for service connection should be historical. Focus on the past instead of describing your current symptoms. Your wife, family, or friends can describe their observations while you were in service, which can be valuable evidence of an incident or onset of symptoms that occurred during active duty.

5. The Timeline and Connection of Conditions Is Important

Evidence for secondary claims should focus on the timeline and the link to your service. If your condition did not start in service but was caused by another service-connected disability, your evidence should highlight your new condition’s history. You should describe how the new condition has developed or worsened since you began experiencing the symptoms of your service-connected disability. In addition to your Lay Statement, which will describe the timeline of your new condition and your symptoms, you can provide medical research that supports the link. 

An example could be a secondary claim for erectile dysfunction in connection to PTSD. There are many research articles establishing the correlation between chronic mental health disorders and sexual dysfunction. Every secondary claim should include the most recent peer-reviewed medical literature available.  

Most medical conditions affect each other because the body is a complex organism with many inter-connected organ systems that all interact. Many medical studies prove these connections, and although everyone is different, predictable patterns exist and are highlighted in medical research studies. A little research can provide you with adequate support for the connection of certain symptoms. And given that your disability status is in question, it’s worth it to put in the extra effort. 

6. Presumptive Claims Require Proof of Exposure

Presumptive claims attempt to link your disability to prior exposure of harmful toxins or chemicals that occurred during service. For presumptive claims, your evidence should focus on proving exposure and establishing a current diagnosis. Most exposure can be established with evidence of your service location and dates. Pictures are powerful evidence and can help you win a case. Many Veterans exposed to Agent Orange during the Vietnam conflict have struggled to prove their exposure due to poor record-keeping at the time. Many of these claims have been won based on photos, letters, and even military memorabilia. 

You may not have access to confidential documents that prove your exposure, but any evidence you can provide can help connect your symptoms to your exposure.

7. Chart How Your Symptoms Get Worse

The escalation of any symptoms or diagnoses is the basis for an aggravation claim. Evidence should focus on the progressive worsening of your symptoms and the link to your service or service-connected prior claim. To prove an aggravation claim, you must not only show that your condition has worsened beyond its natural progression, but that your service or another disability caused the escalation. 

It can seem complicated, but all successful claims must somehow be tied to your service. An entrance physical that notes a condition as asymptomatic can be powerful evidence for your claim if it is followed by documentation of emerging symptoms, changing medications, or new treatments. You want to chart the escalation of the disease or disability. 

Medical literature that shows how certain physical or medical conditions are linked can help win a claim for aggravation. If your symptoms, disease, or condition has advanced more rapidly than normal, be sure to mention it. This aggravation could help you win your claim.

Hopefully, this review of supportive evidence and how it relates to your various claims can help you collect all the proper information, paperwork, and proof you need to get the highest rating that you medically, legally and ethically qualify for. The type of evidence you need depends on the type of claim you file. Stay focused on the relevant information, develop a full understanding of the claim process, and then secure any evidence that validates your claim.

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