House VA Disability Assistance Subcommittee Examines Adjudication of Complex Claims

United States CapitolOn December 4, 2013, the House Veterans’ Affairs Subcommittee on Disability Assistance and Memorial Affairs conducted a hearing to examine how the Department of Veterans Affairs (VA) adjudicates complex claims.  The Subcommittee considers complex claims as those with multiple issues and claims for veterans with Post-Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), veterans who may have experienced Military Sexual Trauma (MST), and veterans who receive Special Monthly Compensation (SMC). 

The most emotional testimony of the hearing was provided by a widow of a Vietnam veteran who has had a claim pending for Dependency and Indemnity Compensation (DIC) benefits for more than 23 years.  Her claim has been denied and appealed many times due to different questions raised by the VA over the years. 

Sherman Gillums, Jr., Paralyzed Veterans of America's Associate Executive Director for Veterans Benefits, testified on behalf of Paralyzed Veterans of America (Paralyzed Veterans).  Mr. Gillums explained that since complex claims involve veterans with catastrophic disabilities, Paralyzed Veterans has a unique expertise given the nature of our membership.  Our service officers have honed a unique expertise in developing and advancing the most complex claims in the system. Where Special Monthly Compensation claims are often the exception for most accredited representatives, they are common for Paralyzed Veterans.

Gillums emphasized that while the Veterans Benefits Administration (VBA) has made tremendous strides in reducing the backlog since launching its 21st century transformation initiatives, complex claims remain problematic because disability benefits questionnaires, evaluation builders, and rules-based calculators oversimplify cases that require critical thinking and inductive reasoning, not algorithms, to adjudicate with true accuracy.  The problem in defining accuracy is complex.  Gillums explained that “if by accuracy VA means the veteran generally receives maximum entitlement, then accuracy targets remain unmet.”  A veteran with a catastrophic disability will usually receive an accurate SMC rating under VA's definition based on limited evidence and binary rules but not the most accurate SMC rating possible that reflects the true extent of disability or need.   

This problem is reflected in the difficulties Paralyzed Veterans service officers have experienced when submitting claims for Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease).  Since the passage of the presumptive rule on ALS opened entitlement to veterans and survivors, Paralyzed Veterans has worked over 6,200 ALS claims, which has made our field staff well-versed in the issues with these complex cases and demonstrative in our insistence that they are timely and accurately adjudicated.  In one particular case, a veteran diagnosed with ALS received notice that he needed to submit to a Compensation & Pension (C&P) exam to prove his need for skilled care despite presenting competent medical evidence of such need from his treating physician.

The rater, an experienced rating coach, was bound by VA’s quality-driven rule that C&P exams are mandatory, even though he had enough evidence to grant the claim at the (r)(2) SMC level.  Unfortunately, the words "hospice" and "skilled care" noted in the medical records simply triggered the requirement to order a C&P exam in the name of quality instead of serving as prima facie evidence of imminent death thus substantiating entitlement based on need for regular skilled care.  In this case, common sense gave way to a calculator, which is supposed to be an assistive tool in decision making, not a replacement for one's reasoning faculties.

Paralyzed Veterans understands the dilemma VA faces under pressure to reduce the claims backlog while also achieving timeliness and accuracy targets.  But not every aspect of this problem is a numbers game.  In the case of complex claims, there are no shortcuts to doing them right.  They require experienced minds that are free to apply common sense and pro-veteran legal principles in the qualitative deliberation of claims with no black-and-white answers.   Ultimately, we believe accuracy is measured by whether VA has provided the maximum benefit possible in these complex claims.

Read Gillums' statement from December 4, 2013 

Learn more about Paralyzed Veterans of America on Capitol Hill 

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    House VA Disability Assistance Subcommittee Examines Adjudication of Complex Claims