January 20, 2017

The appeals process: Appeals and claims are as different as apples and oranges

Catherine Trombley
Dept. of Veterans Affairs

When I represented Veterans at the Board of Veterans’ Appeals, my clients usually had a lot of questions about the appeals process and the differences between a claim and an appeal.

Even in my current position as a public affairs specialist for the Veterans Benefits Administration, I continue to get asked the same questions, so I thought I’d explain the process and address common questions through a series of blog posts.

What’s the difference between a claim and an appeal?
Often when I speak to many of you, you will say something like, “I have had a claim pending for 10 years.” Almost always, you have an appeal pending and not a claim. I don’t say this to undermine the frustration you feel from being in an appellate status for so long.  But understanding the difference between a claim and an appeal, and using the correct term can help your VA representative know where to look, or advise you when discussing your case.

Claims defined
You submit a claim when seeking VA disability benefits (or increased benefits) for one or more medical conditions you believe are related to military service.  These claims can be filed online through eBenefits, submitted by mail or in person at the nearest VA regional office.  The claim submission, the military service and health care records and any other evidence associated with the claim are reviewed in order to provide you a rating determination.

Every claim in VA’s inventory is as distinct as the Servicemember, Veteran or survivor who filed it. A complex set of laws, regulations and court decisions govern how, and to whom, VA administers benefits.  The laws and the process allow Veterans and their survivors ample opportunity – and even assistance – to provide VA the evidence necessary to approve their claims.

Under those laws, VA grants service connection and pays disability compensation (if warranted) for a disability when evidence shows three things: injury or illness in service, a current disability and a link — usually medical evidence — connecting the two. The laws also allow for service connection for conditions caused or aggravated (permanently worsened) by conditions that are already service connected.

Once the decision is made to grant service connection, VA examines the medical evidence and assigns a level of disability under the VA Schedule for Rating Disabilities. You are always afforded the benefit of the doubt. This means that if the evidence is weighed equally, 50 percent in your favor and 50 percent against, the claim is granted or the higher of two evaluations is assigned.

You can work with a state, county or Veterans service organization. These accredited service officers can help you sort out the best option for you claim.   They cannot charge a fee during the claim process, and they provide guidance that can help identify and obtain the evidence necessary for VA to grant a claim.  Remember, there are options for receiving assistance with a claim, so look for someone who files online, provides information about the Fully Developed Claims Program and takes time to answer questions.

What I continue to find interesting is that the accuracy of claim decisions has little bearing on whether we appeal our claims. In fact, regional offices with the highest quality can often have the highest appeal rates.  That’s not to say processing errors don’t happen, they do, and VA continues to work to improve claims accuracy. Currently, VBA’s accuracy rate at the issue (or medical contention) level is 96 percent and the percentage of claim decisions being appealed remains in line with historical averages of 10 to 12 percent.

The appeals process
The multi-stage appellate process is available to you after you have already received one or more decisions on your claim, but disagree with some aspect of VA’s decision.  During the appellate process, an appeal undergoes additional independent reviews, often multiple times and by different adjudicators, as you or your representative submit new evidence and/or a new argument. Nearly 74 percent of appeals are from Veterans who are already receiving VA disability compensation, but are seeking either a higher level of compensation or payment from an earlier effective date.

Once an appeal has been filed, a Veteran may also engage an attorney, but at his or her own expense. Attorneys’ fees are typically taken straight off the top of any retroactive award received from VA.
An appeal is different from a claim. I know firsthand that sending one or the other to VA can seem like the same thing, but understanding the difference and using the right terminology will help VA and your designated representative provide the best information in the quickest amount of time.

Editor’s note: This is the first blog post in a series of articles focusing on appeals.

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