Veterans benefits for post-traumatic stress disorder in the United States

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File:U.S. Army Medic.jpg
U.S. Army Medic

The United States provides a wide range of benefits for veterans with posttraumatic stress disorder (PTSD), which was incurred in, or aggravated by, their military service. The United States Department of Veterans Affairs (VA) will provide benefits[1] to veterans that the VA has determined suffer from PTSD, which developed during, or as a result of, their military service. These benefits not only include tax-free cash payments[2] but can also include free or low-cost mental health treatment and other healthcare;[3] vocational rehabilitation services;[4] employment assistance;[5][6] independent living support;[7] and more.[8]

VA disability benefits for PTSD have evolved over time, in response to legislation, scientific advances, political pressure, revised diagnostic classification schemes, regulatory changes, case law, and administrative decisions. Veterans advocacy organizations, researchers, clinicians, politicians, administrators, and citizens will no doubt continue to influence how the United States evaluates, adjudicates, and administers the program. For example, current efforts at change or reform include urging the VA to place more emphasis on vocational rehabilitation and treatment versus cash payments; revising the General Rating Formula for Mental Disorders to better reflect problems experienced by veterans with PTSD; establishing a balance between efforts to decrease claims processing time (productivity) with the need for consistency and accuracy of examination results and rating decisions (quality); and considering a veteran's quality of life as a factor in determining the disability rating.

U.S. veterans benefits

History

Revolutionary War Soldiers

Since the founding of the country, the United States has sought to compensate the men and women who have served in its armed forces.[9] In 1917, the U.S. Congress passed legislation emphasizing an indemnity model for veterans disability benefits. Congress sought to clarify and better specify provisions of the law in 1919 amendments to the original bill.[10] Since that year, compensation has been provided to veterans suffering from physical or mental disabilities that were incurred during, or aggravated by, military service, and which have adversely impacted the veteran's ability to work. The amount of compensation provided—both cash payments and VA-sponsored services—are based on the veteran's average impairment in earnings capacity.[11] Since OIF/OEF, PTSD has grown to be the third most compensated disability in the VA after hearing loss and tinnitus.[12]

Effectiveness

Whether disability benefits adequately compensate veterans with PTSD for loss in average earning capacity has been debated. Older veterans age 65 and up rated at 50% disabled or higher for PTSD, including individual unemployability (IU) benefits,[13] receive more in compensation (plus any earned income and retirement benefits such as Social Security or pensions) than nondisabled veterans earn in the workforce and/or receive in Social Security and other retirement benefits.[14] However, younger veterans (age 55 and below) generally receive less in compensation benefits (plus any earned income) than their non-disabled counterparts earn via employment. For example, the parity ratio[lower-alpha 1] for a 25-year-old veteran rated 100% disabled by PTSD is 0.75, and for a 35-year-old veteran rated 100% disabled by PTSD the ratio is 0.69. The parity ratio for a 75-year-old veteran receiving IU benefits is 6.81.[14]

Research indicates that veterans receiving disability benefits for PTSD experience a reduction in PTSD symptom severity, and have lower rates of poverty, homelessness and suicide.[15][16] However, because mental healthcare appointment numbers steadily increase until 100% service connection is achieved and then precipitously decrease, there are concerns that compensation rather than treatment motivate many benefit-seekers.[17] Concerns about malingering are further validated by the number of VA benefit-seekers discovered to have never been in combat and/or the military.[18] Simultaneously, the VA disability helps many with true PTSD, erroneously provides limited resources to many malingers, and fails to identify many with PTSD.

In addition to lost income, a Congressionally-mandated commission,[19] argued that the VA disability benefits program should compensate veterans for non-economic losses, particularly with regard to a veteran's overall quality of life. The U.S. Government Accountability Office analyzed this recommendation and suggested that it be considered as one of three major changes to modernize the VA disability benefits program.[20]

Some scholars argue that the VA disability benefits program is "countertherapeutic" because it provides no incentives to overcome symptoms and problems caused by the disorder, and, in fact rewards veterans for staying sick,[21][22][23] while other researchers take issue with this assertion.[24] In a similar vein, a military scholar, who lost both legs during combat operations in Iraq, suggests that current VA disability benefits policy inculcates in veterans a lack of self-efficacy and fosters dependency.[25][26]

VA disability claims process

This section provides a brief overview of the process for initial claims filing, claim development, and adjudication at the local (Regional Office) level.

Overview

The VA provides a description of the 8-step benefits claims process on its website.[27] This is a brief overview:

1. Claim Received - The veteran has submitted a disability compensation claim in person (e.g., while still on active duty with a VBA (Veterans Benefits Administration) representative visiting his or her base), online (via the Veterans On-Line Application [VONAPP]), or by postal mail to the VBA Regional Office (VARO) assigned to his or her geographical location[28] (legal residence). The VARO sends a letter to the veteran via postal mail confirming receipt of the claim.

2. Under Review - A VSR (Veterans Service Representative[29]) reviews the information submitted by the veteran to determine if VBA needs any additional evidence (e.g., service medical records) to adjudicate the claim.

3. Gathering of Evidence - VA has a legal obligation to help veterans obtain any evidence that will support their claim.[30] For example, the VSR might request a veteran's military personnel records (e.g., to confirm unit assignments), Social Security disability records (if the veteran applied for Social Security disability benefits), or private medical records. The veteran can also obtain such records and submit them to the VBA Regional Office handling his or her claim. If necessary, the VSR will request a Compensation and Pension examination (C&P exam) at this time.

4. Review of Evidence - An RVSR (Ratings Veterans Service Representative)[31] makes sure that all relevant evidence has been obtained, and, if so, renders a decision regarding the veteran's claim. The RVSR refers in part to the General Rating Formula for Mental Disorders[32] when making this determination.

5. Preparation for Decision - It is not clear how this step differs from the previous step. The exact quote from the VA website is: "The Veterans Service Representative [presumably they mean the Ratings Veterans Service Representative] has recommended a decision, and is preparing required documents detailing that decision. If more evidence is required, the claim will be sent back in the process for more information or evidence."

6. Pending Decision Approval - Approval by a supervisor.

7. Preparation for Notification - Preparing the "claim decision packet" (Decision Letter and explanatory materials).

8. Complete - VBA mails the "claim decision packet" to the veteran.

Benefits application procedures

File:VA Form 21-526.JPG
VA Form 21-526

To begin the disability claim process, veterans submit a claim to the Veterans Benefits Administration (VBA), an organizational element of the VA. The VBA, based on their review of medical and psychological evidence, must conclude that the veteran indeed suffers from service-connected PTSD. Reaching such a determination usually requires that the veteran receive a Compensation and Pension examination (C&P exam),[33] which is a forensic[lower-alpha 2] mental health evaluation[34] conducted by a psychologist or psychiatrist at a local VA medical facility or by a psychologist or psychiatrist in independent practice who conducts evaluations for a VA-contracted private vendor.

Veterans apply for compensation benefits by mailing or faxing a form, VA Form 21-526, Veterans Application for Compensation and/or Pension, or online using the Veterans On-Line Application (VONAPP) System.

Obtaining assistance

Veterans may receive assistance with filing a VA disability compensation claim from Veterans Service Officers, also known as "VSO Representatives" or "Veterans Service Representatives",[lower-alpha 3] especially when they are affiliated with a nonprofit Veterans Service Organization. The veteran does not pay a Veterans Service Officer for their services. The VA recommends consulting with a Veterans Service Officer:

VA encourages individuals who are applying for disability compensation to work with an accredited representative ... to assist them ... Being accredited means organizations and individuals must have VA permission to represent Veterans before the Department in their claims for VA benefits. The purpose of this requirement is to ensure that Veterans have qualified and competent representation. These individuals receive specialized training in VA benefits law and procedure.[35]

Although some veterans advocates recommend[36] that veterans learn how to file their own claims so that they retain control over the process, e.g., "... veterans [should] file their own claims without the assistance of any sort of representative ... except for an appeal"[37] (see Post-Adjudication Representation, below, for information regarding legal representation for appeals).

The next two sections briefly describe the two types of Veterans Service Officers.

County veterans service officers

County veterans service officers are public employees of their State's (or Territory's) veterans affairs agency. They are often called County Veterans Service Officers,[38] because a majority of the states have set up local veterans affairs offices in each of the state's counties.[39]

Veterans service officers associated with nonprofit veterans service organizations

Many not-for-profit veterans service organizations[40][41] recruit, train, and support their own veterans service officers to help veterans file claims and navigate the claims process. In order to represent a veteran before the VA, the Veterans Service Organization must either have been Chartered by the U.S. Congress or have received official approval from the U.S. Department of Veterans Affairs to represent veterans in the disability compensation claims process.[42] [lower-alpha 4]

Post-adjudication representation

Veterans may appeal the VBA's decision regarding their compensation claim, and they may ask to be represented by an accredited Veterans Service Officer, attorney, or claims agent in the appeals process. Note that the VA does not require a veteran to be represented by a Veterans Service Officer, attorney, or claims agent.

VA prohibits attorneys or claims agents from charging a veteran for professional services prior to the adjudication of the veteran's claim.[44] A veteran may contract with an attorney or claims agent to represent them in an appeal only after the following three conditions have been met:

Seal of the U.S. Court of Appeals for Veterans Claims

(1) the veteran has filed his or her disability compensation claim;

(2) the claim has been adjudicated (a decision on the claim has been made by the Veterans Benefits Administration); and

(3) the veteran has filed a Notice of Disagreement (NOD) with the VBA Regional Office handling his or her claim.[44]

Unless they agree to work on a pro bono basis, attorneys and claims agents who represent veterans before the Veterans Benefits Administration, Board of Veterans Appeals, and Court of Appeals for Veterans Claims require payment for their services. At the federal court level, most attorneys work for Equal Access to Justice Act fees. These are attorney fees ordered by the court to be paid by the federal government when the government's position in litigation was not "substantially justified."[44]

Disability rating

General rating formula for mental disorders

If VBA determines that a veteran suffers from service-connected PTSD, then they assign a disability rating, expressed as a percentage. This disability rating determines the amount of compensation[45] and other disability benefits the VA will provide to the veteran. The disability rating indicates the extent to which PTSD has deprived the veteran of his or her average earnings capacity. A rating of 0% indicates that a veteran has PTSD but the disorder has not affected his or her ability to work, whereas a 100% rating theoretically means that the veteran is not capable of working at all because of PTSD.[lower-alpha 5]

File:Code of Federal Regulations 38.JPG
Code of Federal Regulations, Title 38--Pensions, Bonuses, and Veterans' Relief

The VA assigns disability ratings for PTSD according to the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130),[46] which specifies criteria for disability ratings of 0%, 10%, 30%, 50%, 70%, or 100%.

Some argue that by relying on the current Rating Formula, "VA uses decades-old regulations developed for mental disorders that do not resemble PTSD", and, consequently, "[i]rrelevant criteria ... may outweigh ... more relevant factors, leading VA to undercompensate veterans with valid diagnoses of PTSD."[47] Similarly, veterans service organizations have argued, for example, that a "... veteran service connected for schizophrenia and another veteran service connected for another psychiatric disorder should not be evaluated using the same general formula" and have supported efforts to revise the Rating Formula.[48]

Concern has been expressed by some RSVRs[31] (VBA 'raters' who adjudicate claims) that automated software discourages their use of independent judgment to evaluate the claim as a whole, a charge senior VA officials reject.[49]

Since 2001, the VA has been revising its disability rating schedule to incorporate medical advances that have occurred since the last review, update medical terminology, add medical conditions not currently in the Rating Schedule, and refine criteria for further clarity, consistency and ease of rater application.[50]

Requests for an increased disability rating

A veteran currently receiving compensation for service-connected PTSD may file a claim for an increase in his or her disability rating (the VA also refers to this as an increased disability evaluation,[51] although increased disability rating is more common), or for individual unemployability: If a veteran believes that PTSD, either alone or in combination with other service-connected disabilities (e.g., diabetes, a back injury, chronic pain, etc.), renders him or her incapable of pursuing and retaining gainful employment,[52] and they meet the eligibility requirements, then they may file a compensation claim based on unemployability[13] using VA Form 21-8940.[53]

PTSD C&P exam

As noted above, the VBA almost always requires a compensation and pension examination (C&P exam) of veterans claiming service-connected PTSD. There are two types of PTSD C&P exams: Initial and Review. The Initial Examination for Post-Traumatic Stress Disorder must be conducted by a VA psychologist or psychiatrist certified by the VHA Office of Disability and Medical Assessment (DMA) to evaluate veterans for this purpose.[54] However, note that the definition of "VA psychologist or psychiatrist" includes psychologists and psychiatrists in private practice who conduct C&P exams for a company that has contracted with the Veterans Benefits Administration (VBA) or the Veterans Health Administration (VHA) to provide C&P exam services on behalf of the VA.[55] Companies with current VBA or VHA C&P exam contracts include Veterans Evaluation Services (VES),[56] QTC,[57] Logistics Health Incorporated (LHI),[58] and Medical Support Los Angeles (MSLA).[59]

The Review Evaluation for Post-Traumatic Stress Disorder can be completed by VA or non-VA psychologists and psychiatrists. Clinical or counseling psychology interns, psychiatric residents, licensed clinical social workers, nurse practitioners, physician assistants, and clinical nurse specialists may also conduct review PTSD exams, although they must be "closely supervised" by a psychologist or psychiatrist.[60]

Some scholars have expressed concerns about the reliability (consistency), particularly inter-rater reliability, and validity (accuracy) of C&P exams for PTSD because:

  • Some VA medical centers do not allocate enough time for C&P psychologists and psychiatrists to conduct a thorough, evidence-based assessment, with less time presumably reducing the validity of the results.[61][62]
  • The time allocated to conduct the exam varies from one to four hours, which in itself indicates a lack of consistency and likely lower rates of inter-rater reliability.[63]
  • One survey of C&P psychologists showed that only 15% followed VA's own guidance regarding best practices[64] for PTSD compensation and pension exams.[65] For example, one of the best practice recommendations is to assess veterans for PTSD using the 'gold standard' Clinician-Administered PTSD Scale (CAPS),[66][67] but the vast majority of C&P psychologists do not use this validated instrument according to the survey.
  • Some VA facilities prohibit examiners from using symptom validity tests to screen or assess for malingering and other forms of dissimulation,[62][68] perhaps because some VA researchers argue that the rate of significant exaggeration or malingering among veterans filing PTSD compensation claims is unknown.[69] Other researchers,[70][71][72][73][74][75] news reports,[76][77] and newspaper editorials[78][79] assert that a sizeable percentage of veterans filing PTSD disability claims exaggerate or feign PTSD symptoms.

Disability Benefits Questionnaire (DBQ)

Mental health professionals document the results of Initial and Review PTSD C&P exams on a Disability Benefits Questionnaire (DBQ).[80] The VA developed Disability Benefit Questionnaires (DBQs) to streamline the VBA ratings process and thereby complete the claims process faster. In addition, veterans may ask their treating clinicians to complete a DBQ and possibly bypass the need for a C&P exam.[81] However, it is important to note that the VA discourages their mental health clinicians from completing DBQs for their patients,[82] and similar recommendations have been offered to private psychologists and psychiatrists whose patients ask them to complete DBQs,[83] because it potentially creates a conflict of interest due to a dual role relationship (serving simultaneously as a treating clinician and a forensic evaluator).[84][85]

C&P psychologists have expressed concern that the DBQ "Symptom List" (Section II, Number 5 on the Initial PTSD DBQ;[lower-alpha 6] Section VII on the Review PTSD DBQ;[86] and Section III on the Mental Disorders DBQ[87])[lower-alpha 7] contains a series of signs, symptoms, and descriptions of functional impairment without any guidance regarding when these items should be endorsed.[88][89] [lower-alpha 8] These C&P examiners argue that such guidance is important because otherwise C&P examiners will (necessarily) use their own idiosyncratic judgments regarding when to endorse each item in the "Symptom List". In addition, the disability rating may be based largely on which "Symptom List" items are endorsed, since these items are drawn verbatim from the examples given for each level of impairment in the General Rating Formula for Mental Disorders.[lower-alpha 9]

Important definitions

Discharge status

In order to be eligible for VA benefits, a veteran must have been discharged under other than dishonorable conditions.[91] Stated differently, if a veteran received a Bad Conduct discharge or a Dishonorable discharge they will, under most circumstances, not be eligible for VA benefits.[92]

In line of duty and exceptions

There are exceptions to the general rule that injuries or diseases incurred in, or aggravated by, military service are eligible for VA disability compensation benefits. For example, such injuries or diseases must meet the in line of duty criteria. "In line of duty means an injury or disease incurred or aggravated during a period of active military, naval, or air service unless such injury or disease was the result of the veteran's own willful misconduct or ... was a result of his or her abuse of alcohol or drugs."[93]

Traumatic stressor

Matthew J. Friedman of the National Center for PTSD notes that:

PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an historical event that is considered traumatic.[94]

File:Dsm-5-released-big-changes-dsm5.jpg
DSM-5

A traumatic stressor is an event that meets Criterion A of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria for PTSD. The definition of PTSD Criterion A in DSM-5 is:

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)

1. Direct exposure.

2. Witnessing, in person.

3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.

4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

The relevant regulation (38 C.F.R. § 4.125(a)), was updated on 4 August 2014 to reflect the publication of DSM-5. However, the required notice in the Federal Register indicated that there are exceptions to this 4 August 2014 effective date:[lower-alpha 10]

Applicability Date: The provisions of this interim final rule shall apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after the effective date of this interim final rule. The Secretary does not intend for the provisions of this interim final rule to apply to claims that have been certified for appeal to the Board of Veterans' Appeals or are pending before the Board of Veterans' Appeals, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit.[95]

Service-connection

The term, service-connected, means that a veteran has a disease or injury that is "connected" to his or her military service, i.e., the disease or injury was incurred in, or aggravated by, his or her military service.[96]

The official definition in the Code of Federal Regulations[97] begins:

Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein.[98]

The relationship between service connection and access to VA healthcare is emphasized in this definition:

"'Service connected' veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system."[99]

Types of military service

United States Coast Guard Academy seal

The regulations describe three categories of military service, active duty, active duty for training, and inactive duty training.[100] Eligibility for VA disability compensation requires that the veteran's service occurred during one of these three categories.[101] The definition of active duty military service includes "service at any time as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy."[100]

Notes

  1. ↑ The CNA report cited herein describes the parity ratio as: "A ratio of exactly 1 would be perfect parity, indicating that the earnings of disabled veterans, plus their VA compensation, gives them the same lifetime earnings as their peers. A ratio of less than one would mean that the service-disabled veterans receive less than their peers on average, while a ratio of greater than one would mean that they receive more than their peers."
  2. ↑ Note that the term forensic in this context simply means legally-related and has nothing to do with criminal law or law enforcement. The veterans disability benefits claims process for PTSD is ultimately a legal proceeding, which is why PTSD C&P examinations are categorized as psycholegal, medicolegal, or, most commonly, forensic mental health evaluations.
  3. ↑ Not to be confused with Veterans Benefits Administration staff whose job title is Veterans Service Representative (VSR).
  4. ↑ Note that the VA sometimes refers to both County Veterans Service Officers and VSO Representatives as "Veterans Service Organizations (VSO) Representatives" or "VSO Representatives." For example, if one conducts an "Accreditation Search" on the VA website[43] and search for a "VSO Representative," the search results will list both County Veterans Service Officers and VSO Representatives.
  5. ↑ The adverb 'theoretically' is used here because the Rating Formula is based on symptoms, not occupational impairment. While the symptoms associated with the 100% rating for mental disorders often cause significant occupational impairment, e.g., "persistent delusions or hallucinations" or "persistent danger of hurting self or others", they do not necessarily render a veteran unable to work.
  6. ↑ The Initial PTSD DBQ is available on the VA intranet only.
  7. ↑ Note that the outline enumeration for the various parts of the DBQs, e.g., "Sections", in Roman numerals, or "Numbers", in Arabic numerals, differ from one DBQ to another, i.e., they are not uniform.
  8. ↑ See also (for a legal perspective): Ridgway, J. D. (2012). Mind reading and the art of drafting medical opinions in veterans benefits claims. Psychological Injury and Law, 5(1), 72-87. doi:10.1007/s12207-012-9119-6
  9. ↑ For example, the "Symptom List" contains the following items: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Each of those signs, symptoms, or descriptions of functional impairment are the exact examples given for the 50% level of impairment in the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130). Accordingly, if the C&P examiner endorses one or more of these items, the veteran will likely be assigned a 50% disability rating, all other factors being equal, particularly given the advent of VBA's automated Evaluation Builder software.[90]
  10. ↑ The terms effective date and applicability date are used interchangeably in the Federal Register.

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  94. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  95. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  96. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  97. ↑ 38 CFR §3.303(a)
  98. ↑ Full text of 38 CFR §3.303(a)
  99. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  100. ↑ 100.0 100.1 Lua error in package.lua at line 80: module 'strict' not found.
  101. ↑ Lua error in package.lua at line 80: module 'strict' not found.

External links

U.S. Department of Veterans Affairs benefits information

Other veterans benefits resources

U.S. government resources for military personnel and veterans

PTSD treatment resources for veterans

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