Claims Denials and the Appeals Process ~ The Particulars
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NOTE : All Veterans or dependents who CAN use the newer Claims System, SHOULD ABSOLUTELY USE THE NEWER SYSTEM! WHY ? Because the VA is commonly rendering Determination Decisions in approximately 125 days under the Appeals Modernization and Improvement Act’s full implementation on Feb 19, 2019. See graphic below showing far lengthier timelines under Legacy System.
All Original Claims and all levels of Claims Appeals received by VA AFTER FEBRUARY 19, 2019 are only processed under the AMA.
Under the AMA’s system, there 2 major categories of Original Claims Submissions, then 7 major categories of Claims Appeals;
First, the 2 major categories of Original Claims ~
➤ “ Fully Developed ” Original Claim ( a Claim with absolutely all Forms and Documentation turned into the VA at the onset of the Claim – Under the AMA initial Determinations – approximately 125 days ). With rare exception, AVBA’s only choice for 1st submissions !
➤ “ Intention to File Claim “ ( used in those rare exceptions vs Fully Developed submissions )
Next, the first 3 APPEALS ” Claims LANES “ ~
1. Supplemental Claim Lane ~ Is then option if you have new and relevant evidence supporting you original Claim. Since full AMA implementation, It sees to be the option for accomplishing Fastest Decisions in the Shortest Timeframe .
2. Higher Level Review Lane ~ This is also called a De Novo or New Look Review. It is most beneficial for those who believe there was a mistake in the initial Claim Denial Determination, such as an already recognized flaw or error in the AMA law or the VA’s incorrect interpretation of the law.
VERY IMPORTANT NOTE ! : If a Vet chooses this path, they may NOT submit or have consideration of ANY claim evidence NOT ALREADY IN VA’s possession ! VA will ONLY consider the SAME EVIDENCE INITIALLY SUBMITTED and already previously reviewed !!
3. Notice of Disagreement Lane ~ ( also known the Appeal to the Veterans’ Board of Appeals Lane, or the Board Lane, or VBA Lane ) –
As if this Claims Process wasn’t complicated enough, Vets choosing this ” Lane “ must then AGAIN CHOOSE FROM ONE OF THESE 3 MORE SUB – Lanes known as “ Dockets ” :
4. The Direct Docket (VA has set goal of Determination within 365 days – No new evidence allowed )
5. The Evidence Docket ( Have only 90 Days after Notice of Disagreement – Additional Evidence is allowed )
6. The Hearing Docket ( For Veterans who want to have a hearing before a Veterans’ Law Judge. The only hearing options available to veterans under appeals reform include a Video Conference hearing and a hearing at the Board in Washington, D.C.)
After working through one or more of the 3 primary “ Lanes ”, and any of the 3 “ Dockets ”, under certain Appeals procedural conditions, Veterans may still be able to appeal to the ~
7. U.S. Court of Appeals for Veterans’ Affairs, ( also known as the Court of Veterans’ Appeals, or CVCA )
IMPORTANT NOTE : Veterans can change their request for a certain review option at any time prior to VA issuing an initial decision on their claim… Specifically, if Veterans disagree with the decision VA made in one of the AMA Lanes, they have the option to appeal to another Lane based on the circumstances of their case.
Also, adding to the possibilities of an already complicated process, it is little-known that even a DENIED APPEALED CLAIM can still be Re-APPEALED, and even RE-RE-APPEALED ! !
AMA Claims 1st Submission Timelines
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Appeals Procedure Flowchart Average VA Appeals.
Retroactively Awarded Benefit Grants
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Another exceptional result stemming from the Veterans’ Appeals Modernization & Improvement Act is that is now more possible to have Claims which have been stifled and impeded within the VA’s labyrinthine Claim, or Claim Appeal Determination jumble for long periods of time to receive RETROACTIVE BENEFIT AWARD GRANTS ! AVBA recently won a Retro-Paid Grant for one of our very deserving Veteran Clients in the amount of $ 121,788.00 ( One Hundred Twenty-One Thousand, Seven Hundred and Eighty-Eight Dollars USD ! ) Click HERE for details !
VA Disability Retroactive Award Grants or Back-Pay are the monies owed to Veterans from the “Effective Date” of their claim, to the date they weree / are granted those benefits called the “ Date of Determination of APPROVAL of Claim ”. Unfortunately due to VA’s backlog of disability compensation claims, the VA can often take months or years to grant benefits. The longer the VA takes to decide your claim, the more back pay it owes you to compensate you all the way back to your effective date.
Appeals Filing Deadlines – Different for Different Circumstances
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Veterans Appeals Deadlines Under the Veterans’ Appeals Modernization & Improvement Act of 2017
• However, if a veteran disagrees with VA’s decision, he or she has one year to appeal by choosing one of the following three lanes: the Higher-level Review Lane, Supplemental Claim Lane, or Notice of Disagreement Lane (i.e. Appeal to the Board of Veterans’ Appeals, aka also known as the Appeal to the Veterans’ Board of Appeals Lane, or the Board Lane, or VBA Lane). After appealing through one of those three lanes, Veterans will then receive another decision. Specifically, both the Higher-Level Review and Supplemental Claim Lane will yield additional Rating Decisions while the Notice of Disagreement Lane will produce a VBA decision:
• Higher-level Review Rating Decision. If a veteran receives an unfavorable decision in the higher-level review lane, he or she has one year to file either a supplemental claim or a Notice of Disagreement.
• Supplemental Claim Rating Decision. If a veteran receives an unfavorable Rating Decision in the supplemental claim lane, he or she has one year to file an appeal in any one of the three lanes.
• Veterans’ Appeals Board Decision. If a veteran receives an unfavorable Board decision, he or she can either file a supplemental claim within one year or appeal to the CAVC within 120 days.
• Court of Appeals for Veterans’ Claims Decision. If a veteran receives an unfavorable decision from the CAVC, he or she has one year to file a supplemental claim, or 60 days to appeal to the Federal Circuit
Veterans’ Appeals Deadlines Under the VA‘s Prior Claims Law, the Veterans’ Claims Assistance Act of 2000, known as “ Legacy Claims / Legacy Appeals ”
The Legacy Appeals System only involved one “Lane” in the Veterans’ Claims and Appeals process. In other words, all Veterans having filed for VA Disability Benefits under Legacy System go through, ( or had to have already gone through ) the same steps and must adhere to the following appeal deadlines :
• After filing an initial Claim, the local Regional Office will issue a Rating Decision that grants, denies, or partially grants the claim. Veterans have one year to file a Notice of Disagreement (NOD).
• VA will then issue a Statement of the Case (SOC), explaining why the Claim was denied or only partially granted. Veterans have 60 days from when VA issues the SOC to file a Substantive Appeal to the Board of Veterans’ Appeals.
• The Board will then issue a decision granting, denying or remanding the Claim for further action. If veterans are appealing a further denial, they have 120 days to appeal to the Court of Appeals for Veterans Claims (CAVC).
• If veterans are denied at the CAVC, they have 60 days to appeal to the Federal Circuit.
5 Possible Ways the VA Establishes / Determines Veterans’ Claim “ Effective Date ”
Every Claim and every Appeal of any Claim Denial must have a finite, VA determined “ Effective Date ”. VA calculates Retroactive Award Grants’ all-important Effective Dates in one of three different ways :
1. For 1st Submission, Service-Connected Disability Claims and S-R Appeals, normally the date the VA receives / received your claim, no matter how long ago that was.
2. For Appeals Claims where the Veteran(s) seek a Disability Rating Increase, if granted the Back-Pay Effective Date will probably be the date which VA received the Appeal, not the VA’s receipt date of the original Claim Submission.
3. For “ Supplemental Claims Lane ” submissions where new medical evidence shows a Service-Connected Condition worsened PRIOR TO THE SUBMISSION of a Rating Increase Claim, the Effective Date should be the earlier Date when the medical evidence reflects the worsened condition.
4. For Military Service members just “ Service Separated ” (all EXCEPT Less than Honorable or Dishonorable Discharges) claiming PTSD, or other commonly recognized conditions, Effective Date usually considered the DAY AFTER separation.
5. In the extremely rare circumstance involving Veterans’ S-R Disability Claims, where Claimant(s) had involvement with the 1986 Class Action Lawsuit called Nehmer vs U.S. Department of Veterans Affairs, brought against VA by the National Veterans Legal Services Program ( NVLSP ) a complex formula is used to determine the individual Vet’s Effective Date. Nehmer Effective Dates are almost always far before the VA’s initial “ Receipt of Original Claim ” date. NOTE : The Spouses, Dependent Parents or Dependent Children of Veterans who died from such exposure may also be eligible for benefits.
Two common misconceptions about VA Retro-Pay are that the VA will pay Veterans all the way back to the date of the injury or event in service, or, that the VA will pay Veterans all the way back to the date of their discharge. The VA does not consider the date of an event or injury to be an effective date for those who apply for Disability Compensation after they have separated from service.
Some Much Needed Appeals Tips & Tricks !
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First – The Tips
Tip One ~
1. Really want your Claim Denial Determination reversed, or your low Disability Rating raised ? Consult Experts ! Our initial consults, for Appeals or Initial Claim Evaluations ARE FREE – 818 999 9910 / AVBA@email.com
AVBA has won hundreds of Denial Appeals and hundreds of Rating Increases ! ( Click HERE for some of our actual Official VA Awards ! ) Our staff has over a combined 40+ years of VA Claims WINS experience ( Appeals and New Claims ) with commensurate Claims “ Packaging ” expertise ! Our own VA Certified Accredited Claims Agent (Click HERE for his Credentials) is frequently consulted by Attorneys and even Veterans’ Service Officers ( VSO’s are VA employees ! ) supposedly specializing in helping Veterans but who, in reality ~
• Don’t have A CLUE about how to process Claims or Claims Appeals
• Too often, really TOTALLY, COMPLETELY AND THOROUGHLY Botch UP ( as nicely as we could express it ! … Do any “ Word Wizards ” or “ Acronym Acrobats ” out there recognize F.U.B.A.R. from WWII ?? ). It’s a more accurate commentary on what inexperienced “ Pretenders ” can do to devastate a Claim File ! Often this kind of devastation is a Claim’s death knell – even a masterful Staff such as AVBA’s can not resurrect or reincarnate.
Tip Two ~
2. Be SURE that your Claim Appeal Submission :
a ) has ALL OF THE CORRECT VA FORMS
b ) has THE VERY MOST CURRENT VERSIONS OF EACH FORM ! There are more than 60 forms relating to Appeals. The VA updates these forms every few years; find the dates and Form Numbers in either the lower left or lower right of every Form.
c ) by following 2 a ) and 2 b ), your Claim Submission is considered a “ Fully Developed ” Claim and the VA will likely ( but not guaranteedly ! ) process it under the RAPID APPEALS MANAGEMENT PLAN ( RAMP – which came as part of the Veterans’ Modernization and Improvement Act ). Under this Law, RAMP Appeals are mandated to receive a Determination of Claim within 125 Days, which, according to internal sources at the VA is being accomplished, by and large. Remember, the 125 Day Threshold applies to RAMP Appeals.
NOTE : The most “ current ” version of these Forms are almost never dated the current calendar year !
Tip Three ~
3. Although the VA is modernized enough to have email and still, fax, when it’s time to do your actual Claim Submission for greatest success and most rapid determination, AVBA strongly recommends ~
• Sending the package via United States Postal Service’s Certified Mail, Return Receipt Requested for its tracking capabilities and ITS SIGNED, DATES WRITTEN PROOF that VA has received it !
• Hand delivering it to a VA Facility and making sure to get a dated, time stamped copy of your Cover Page.
• Strongly Recommends AGAINST faxing or e-Mailing a Claim Appeal Package, Notice of Disagreement or Initial Claim Submission
• Strongly Recommends AGAINST trying Veterans’ Service Officers, Veterans’ Service Organizations ( such as USO, VFW, American Legion, etc, etc ). They mean well but almost never have the expertise or up-to-the minute VA knowledge to succeed, and may severely mangle an Appeal beyond repair.
Next ~ The 3 Tricks
Although the Veterans’ Appeals Modernization and Improvement Act legally officially eliminated some previously required Claims documentation, AVBA HAS HAD GREATEST SUCCESSES IN WINNING REVERSALS of previously Denied Claims BY ABSOLUTELY, POSITIVELY STILL INCLUDING these 3 DOCUMENTS !
Trick One ~
• ALWAYS INCLUDE a “ Nexus ” Letter ( A specially and VERY specifically worded missive from a licensed Physician ).
Trick Two ~
• ALWAYS INCLUDE “ Buddy ” Letter(s) ( Letters from friends stating their personal knowledge of your conditions and
problems you are experiencing ).
Trick Three ~
• ALWAYS INCLUDE Disability Benefits Questionnaire. DBQ’s are forms used by VA physicians when performing
Compensation & Pension Exams for VA Disability. The purpose of a DBQ is to ensure that the physician performing the exam
records all the information needed to properly rate a Disabled Veterans’ conditions. The Veteran Affairs Schedule For Rating
Disabilities ( V A S R D ) is a federal regulation – CFR 38, Book C, which lists detailed requirements for assigning Official
Disability to conditions for Military Disabilities and has very specific requirements for rating every condition.
VA’s Claims Appeals Statistics – A Look at The Numbers
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The Department of Veterans’ Affairs ( VA ), has 2 departments mandated to monitor ALL Veterans’ Claims.
• The first is The Veterans’ Benefits Administration in the Office of the Inspector General
• The second is the The Board of Veterans’ Appeals
The Latest VA Claims Statistics
Most current numbers from the Veterans’ Benefits Administration indicated that that VA Disability Appeals success rate is 35.75 percent. Information from the private Vets’ assistance organization and VA Watchdog agency, Veterans’ Advocacy Associates reports that this figure includes both Veterans’ self-submissions, as well as submissions by Accredited Claims Agents, Disability Attorneys, and Veterans’ Service Organizations.
And yes, a 35.75 percent Disability Appeals Approved percentile regrettably equals a 64.25 % DENIED Percentage ! OUCH!! Some MUCH BETTER NUMBERS !
Here are AVBA’s “ Awarded Compensation Benefits ” and “ Awarded Pension Benefits } numbers : First, for Service-Connected Disability Claims ( S – R D C ) :
With hundreds and hundreds of Claim Successes since 2008, call us for your FREE Consultation and Claim Evaluation, you’ll be GLAD YOU DID !
Since 2008, American Veterans’ Benefits Alliance has succeeded in having over 1,700 Veterans, Surviving spouses, family members, dependent children and dependent parents be Approved for, Granted and Awarded the Pensions, Compensations, and retro-paid lump sum benefits they so truly deserve with:
• Original, First Time Submission Claims for Veterans , covering both Service-Connected Disability and NON Service- Connected Claims Original, First Time Submission Claims for Surviving spouses, family members, dependent children ( known as Dependency & Indemnity Claims )
• Supplemental Claims ( when Veteran suffers another Service-Connected Disability condition some time after the after the first Claim Approval )
• APPEALS of Veteran Clients’ Claims previously APPROVED, but where the Veteran believes the VA has given a Disability Rating unsuitably below what is flt to be fair and equitable and thus, is Appealing to try for a Higher Ratiing / Higher Compensation
• APPEALS of Veteran Clients’ Claims previously DENIED by the VA. And, with the help of the some very beneficial provisions of Veterans Appeals and Improvement Act of 2017, WINNING DOZENS of very substantial “ LUMP SUM Retro – Payment ” Grants ( These are one-time, Service-Connected Disability compensation benefit awards covering a period from the VA’s official original receipt of Claim Date through to the month that the previously DENIED Claim is reversed to an Approved Claim.
Click HERE for details on our most substantial Service-Connected Disability Retro-Award to date – $ 121,788.00 !
We’ve assisted hundreds and hundreds of deserving Veterans and we stand ready to serve you ! With hundreds and hundreds of Claim Successes since 2008, call us for your FREE Consultation and Claim Evaluation, you’ll be GLAD YOU DID !
