If you do not understand how VA rates or weighs TBI residuals this article will help.
Are Your VA TBI Residuals Related to Service?
Before VA will assign a rating for TBI, it must first determine whether it is related to service. The question is whether VA should award service connection for TBI. Generally, VA will deny service connection for TBI unless the following elements are met:
Proof of a current diagnosis,
Proof of an in-service event, disease or injury,
and
Proof of a medical nexus between the first 2
elements.
Do you have a current TBI diagnosis
If you file a claim for TBI without a confirmed diagnosis, then you should expect VA to deny the claim. It is not enough for the veteran to say they have VA TBI residuals. Before VA will rate TBI, it must confirm that it has been medically diagnosed. For VA purposes, only one of the following specialties can diagnose TBI:
Neurologist,
Neurosurgeon,
Physiatrists, or
Psychiatrist.
Traumatic brain injury (TBI) occurs when a sudden trauma causes damage to the brain. If you had sudden head trauma during service, you may have VA TBI residuals in the following areas:
Cognitive (such as decreased memory, concentration, or attention),
Emotional/behavioral (such as anxiety, crying spells, short temper), or
Physical (such as seizures or balance problems)
If you have any of these symptoms, then you should probably get checked for a TBI. To prove the current diagnosis element, one of the approved specialties must provide the diagnosis.
In-service event, disease or injury
According to the Department of Defense, more than 313,816 service members have sustained a TBI in training or combat. Common causes of this kind of head trauma include blast-related concussion events resulting from training or combat. In fact, TBI is known as a signature injury of the Iraq and Afghanistan wars due to the frequency of IED attacks. However, a simple fall down a 10-foot ladder could also damage the brain.
If you cannot prove that your VA TBI residuals are related to service, then VA may assume that it happened after discharge. For this reason, it is critical that service members document any and all head injuries. Your case is much easier to win if head trauma is clearly documented in your service medical records. In the absence of official records, statements from witnesses would be helpful.
Medical nexus is required to prove VA TBI residuals
Proving the first 2 elements of the claim is not enough. To win a TBI claim, you still need medical evidence linking your current diagnosis to the in-service event. In most cases, a statement from your doctor can provide a medical nexus.
Fortunately, a medical nexus does not have to express 100% certainty. Instead, here is the question: is it at least a 50/50 chance that the TBI was caused by in-service head trauma? If your doctor’s answer is “Yes” and he provides a reasonable explanation, then you have your medical nexus.
Rating VA TBI Residuals
After VA concedes service connection for TBI, it turns to the rating percentage. The rating percentage determines how much money VA must pay to the veteran. The ratings for TBI residuals are covered in the VA Schedule of Ratings.
VA divides the rating criteria for VA TBI residuals into 10 categories. Veterans are then rated based on the level of severity and impairment in each of these areas:
Memory, attention, concentration and executive
functions: Executive functions include goal setting, planning, self-monitoring,
and flexibility in changing actions when they are not productive.
Judgment: Is the veteran able to make reasonable
decisions?
Social interaction: How often does the veteran
act appropriately in social situations?
Orientation: Is the veteran aware of who, where,
and when he is?
Motor functions: Is the veteran able to perform
previously learned motor activities (such as riding a bike)?
Visual spatial orientation: Does the veteran get
lost even in familiar surroundings? Is
he able to point at or name own body parts?
Subjective symptoms: Symptoms that cannot be
measured with objective tests, such as panic attacks and thoughts of suicide.
Neurobehavioral effects: Examples include lack
of motivation, verbal aggression, physical aggression, and lack of empathy.
Ability to communicate: Can the veteran
communicate either by spoken or written language? Can he communicate basic needs?
Consciousness: Is the veteran in a coma or a
vegetative state?
VA rates TBI residuals on a scale of 0, 1, 2, 3, or total. Each increment corresponds to a disability rating:
0 = 0% (normal functioning)
1 = 10% (mild)
2 = 40% (moderate)
3 = 70% (severe)
Total = 100%
If any residuals of TBI are rated “total”, then VA will award a 100% rating. If no residual is rated “total”, then VA must rate based on the highest rated residual. For example, let’s say a veteran has TBI residuals in 3 out of the 10 categories. He has a 1 for Judgment, a 3 for Ability to Communicate, and a 2 for Orientation. In this example, VA will award 70% because 3 is the highest residual rating.
Because memory deficits are common VA TBI residuals, a veteran should always have an advocate. Disability Help Group specializes in TBI cases and is here to answer your questions now.
VA rates TBI residuals on a scale of 0, 1, 2, 3, or total. Each increment corresponds to a disability rating. 0 = 0% (normal functioning); 1 = 10% (mild); 2 = 40% (moderate); 3 = 70% (severe); or Total = 100%.
How does VA review TBI residuals?
VA divides the rating criteria for VA TBI residuals into 10 categories. Veterans are then rated based on the level of severity and impairment. For example, Neurobehavioral effects include lack of motivation, verbal aggression, physical aggression, and lack of empathy.
What medical nexus proves TBI?
To win a TBI claim, you still need medical evidence linking your current diagnosis to the in-service event. In most cases, a statement from your doctor can provide a medical nexus.
Understanding the basics will help you learn how VA Rates TBI. Traumatic brain injury (TBI) occurs when a sudden trauma causes damage to the brain. According to the Department of Defense, more than 313,816 service members have sustained a TBI in training or combat. Common causes of this kind of head trauma include blast-related concussion events resulting from training or combat. In fact, TBI is known as a signature injury of the Iraq and Afghanistan wars due to the frequency of IED attacks. However, a simple fall down a 10-foot ladder could also damage the brain. Any veteran who suffered TBI during service should obtain a VA rating to fairly compensate for this significant injury.
Only Specific Doctors can Diagnose TBI
Because TBI involves damage to the brain, it may affect nearly every other body system. Any symptoms secondary to the initial brain trauma are called residuals. Before VA will rate TBI, it must confirm that it has been medically diagnosed. For VA purposes, only one of the following specialties can diagnose TBI:
Neurologist,
Neurosurgeon,
Physiatrists, or
Psychiatrist.
Ultimately, TBI is a medical question best answered by a doctor. However, a veteran and his family should be on alert if any common TBI residuals present themselves.
Common Residuals – VA Rates TBI
There are 3 main areas of dysfunction that may result from TBI:
Cognitive (such as decreased memory, concentration, attention, and executive functions of the brain)
Emotional/behavioral (such as anxiety, crying spells, panic attacks, short temper), and
Physical (such as motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems).
If you have any of these symptoms after a sudden hit to the head during service, then you should get checked for TBI immediately.
VA Rates TBI
After VA concedes service connection for TBI, it turns to the current TBI residuals. VA divides the rating criteria for TBI residuals into 10 categories. Veterans are then rated based on the level of severity and impairment in each of these areas:
Rating based on level of severity
Memory, attention, concentration and executive functions: Executive functions include goal setting, planning, self-monitoring, and flexibility in changing actions when they are not productive.
Judgment: Is the veteran able to make reasonable decisions?
Social interaction: How often does the veteran act appropriately in social situations?
Orientation: Is the veteran aware of who, where, and when he is?
Motor functions: Is the veteran able to perform previously learned motor activities (such as riding a bike)?
Visual spatial orientation: Does the veteran get lost even in familiar surroundings? Is he able to point at or name own body parts?
Subjective symptoms: Symptoms that cannot be measured with objective tests, such as panic attacks and thoughts of suicide.
Neurobehavioral effects: Examples include lack of motivation, verbal aggression, physical aggression, and lack of empathy.
Ability to communicate: Can the veteran communicate either by spoken or written language? Can he communicate basic needs?
Consciousness: Is the veteran in a coma or a vegetative state?
TBI disability rating
0 = 0% (normal functioning)
1 = 10% (mild)
2 = 40% (moderate)
3 = 70% (severe)
Total = 100%
If any residuals of TBI are rated “total”, then VA will award a 100% rating. If no residual is rated “total”, then VA must rate based on the highest rated residual. For example, let’s say a veteran has TBI residuals in 3 out of the 10 categories. He has a 1 for Judgment, a 3 for Ability to Communicate, and a 2 for Orientation. In this example, VA will award 70% because 3 is the highest residual rating.
Special Monthly Compensation -VA Rates TBI
If you are trying to get the most VA compensation for TBI, then do not stop at the standard rating criteria. Depending on the circumstances, a veteran may be entitled to Special Monthly Compensation for TBI. This would be in addition to any ratings VA assigns under § 4.124a.
How We Won This Case
We represented a 30 year-old combat veteran of the Army. He came to us with a 10% rating for residuals of TBI. After developing the case, we urged VA to rate his TBI residuals at no less than 70%. In addition, we discovered that his mother had been his primary caregiver since his return from military service. Among other duties, the veteran’s mother assisted with medication management, personal hygiene, reminding him of and taking him to appointments, and paying his bill. The local VA hospital had already appointed the mother as his VA caregiver. We argued that the record clearly showed the veteran has a permanent need for regular aid and attendance due to his TBI. In response, VA increased the TBI rating to 70% and granted Special Monthly Compensation at the (r)(2) rate. As a result, the veteran’s monthly payment changed from $264.02 to $8,343.91.
Every C&P exam involves the doctor asking questions of the veteran. The doctor relies on the veteran to explain his symptoms, some of which may not present or observable on the day of the exam. Because memory deficits are common TBI residuals, a veteran should attend C&P exams with a spouse, family member, or friend who knows them well. They can fill in the blanks if the veteran is unable to either remember or communicate certain residuals during the exam.
VA Nexus Letter for PTSD. VA will pay disability compensation to a veteran if he proves his disability is related to military service. As part of the process, VA uses disability nexus letters to figure out whether a disability was caused or aggravated during service. If the answer is “No”, then VA will not pay for that disability.
Will You Need a VA Medical Nexus Letter for PTSD?
Not every VA claim needs a nexus letter because in some cases, the link to service is undeniable. For example, if your service records include a diagnosed disability you still suffer from today, then VA would probably grant a claim for that disability without a nexus letter. In claims for certain chronic conditions, VA will concede a relationship to service if there is a diagnosis within 1 year of discharge.
However, what if you don’t have a diagnosis until many years after service? For example, Vietnam veterans with Agent Orange exposure usually don’t develop herbicide-related disabilities (such as diabetes mellitus type II) for several years. The gap from discharge to diagnosis can be even greater with mental health disorders. Many veterans respond to traumatic in-service events by trying to cope on their own. Coping mechanisms include self-medication with drugs or alcohol, avoidance of medical treatment, and withdrawal from social situations. When the symptoms get much worse and they finally seek mental health treatment, a doctor renders a diagnosis of PTSD. To win this kind of claim, a strong disability nexus letter for PTSD is essential.
Who should Write Your VA Nexus Letter for PTSD?
Only a medical professional with the appropriate medical training should write a disability nexus letter. In limited circumstances, non-doctors such as physician’s assistants and nurse practitioners can write them. However, VA will find a disability nexus letter more persuasive if written by a doctor in the relevant specialty. For mental health disorders such as PTSD, a psychologist or psychiatrist would be ideal.
From time to time, VA will ask affiliated doctors to write disability nexus letters. However, most of those are not favorable to the veteran. Give yourself the best chance to win by seeking an independent disability nexus letter. If applicable, you should have your treating doctor write one. That doctor is probably more knowledgeable about your condition than any of VA’s hired guns.
Requirements for a VA Nexus Letter for PTSD
VA will only accept a disability nexus letter if it meets certain requirements. A strong disability nexus letter for PTSD must include:
A discussion of relevant medical history from
service to the present day,
The likelihood that the PTSD was caused or
aggravated during service, and
A reasoned explanation for the conclusion.
Medical History
The medical history from service to the present day is especially relevant to what caused PTSD. Even the PTSD diagnosis happens years after service, the onset of the disability can be shown in service records. Let’s say a veteran claims that racial harassment during service caused a persistent PTSD disability. The service medical records don’t show treatment for PTSD. However, the personnel records showed a drastic change in behavior 5 months prior to discharge. His first 5 years of service included multiple commendations for performance. In the last 5 months, he received multiple Article 15 punishments. A good disability nexus letter would consider whether the sudden behavioral change marked the onset of PTSD.
How likely is PTSD related to service?
The burden is on the veteran to prove his claim. However, the standard of proof is much lower than in a criminal case. The doctor who writes the nexus letter does not have to be 100% sure of the link. Because this is a veteran-friendly system, VA requires at least 50% certainty. If your doctor finds there is at least a 50/50 chance that your PTSD is related to service, then that is enough to win. In other words, a good disability nexus letter states that it is “at least as likely as not” that the disability is related to service. A strong nexus letter would express “more likely than not” certainty.
A doctor is more likely to write a good disability nexus letter if PTSD clearly existed from service to the present day. You can improve your odds by giving your doctor any of the following:
Your full service medical and personnel records,
Lay statements from friends and family who
observed your behavior from service to the present day, or
Post-service medical and/or arrest records
relevant to PTSD.
What is the doctor’s reasoning?
In a disability nexus letter for PTSD, 80% of the value comes from the doctor’s reasoning. If the letter only contains data and conclusions, then it won’t help the case. At a minimum, the reasoning must be clear, concise and supported by valid medical analysis.
For example, let’s say you are seeking a medical nexus letter for PTSD. After reviewing your medical history, your psychologist agrees that “it is at least as likely as not that” your PTSD was incurred during your military service. Her medical nexus letter should explain why the in-service symptoms and the post-service diagnosis matters. It should also cite any medical literature that supports her opinion. If there was any post-service trauma, she should explain how it only made the existing PTSD worse.
What is a VA Disability Nexus Letter for PTSD? If you’re reading this, then you are probably familiar with the basics of a VA disability claim. Before we discuss what a medical nexus letter is lets review the basics. To win a VA disability claim, the veteran must prove all required elements of that specific claim. In general, VA will only grant your claim if you prove these 3 elements:
Current diagnosis of a disability,
In-service event, disease or injury, and
Medical nexus between the first 2 elements.
A veteran’s doctor can provide a current diagnosis. Either service records or witness statements can prove the in-service event. The medical nexus requirement is often the most challenging element to prove.
What is a VA Disability Medical Nexus Letter for PTSD?
A good medical nexus letter can be the difference between winning your PTSD claim and losing it. However, it is not enough for a doctor to state that the current diagnosis is related to the in-service event. Unless the letter meets certain requirements, VA will not accept it as evidence. A strong medical nexus letter should:
Be written by a qualified medical professional,
Be based on the veteran’s medical history both
during and after service,
Include an opinion on the likelihood that the
veteran’s disability was caused or aggravated by the in-service event, and
Include an explanation for the opinion that is
easy to understand.
VA Disability Nexus Letter for PTSD: Qualified medical professional
As the term suggests, only a medical professional can provide a medical nexus letter. This means that a veteran should only seek this from someone with the appropriate medical training. In limited circumstances, non-doctors such as physician’s assistants and nurse practitioners can write medical nexus letters. However, keep in mind that VA may get a competing nexus letter from someone more qualified than a nurse practitioner.
In all cases, a veteran should seek the most competent medical professional for this important task. For example, if you need a medical nexus letter for PTSD, then you should probably consult a mental health professional like a psychologist or psychiatrist. A PTSD nexus letter from an orthopedist probably would not help your case. Choose your author wisely, and make sure the letter includes his/her qualifications and contact information.
VA Disability Nexus Letter for PTSD: Medical history provides context
When it comes to what caused a disability, context is everything. If the medical professional doesn’t know the service and post-service medical history, then how can he tell what caused the disability? This requirement helps VA avoid paying veterans for disabilities unrelated to service. Let’s say a veteran is seeking a medical nexus letter for PTSD and PTSD. He tells his doctor that the PTSD must have been related to racial discrimination he suffered in service, and the PTSD followed soon after. However, his medical records show there was no PTSD diagnosis until he was involved in a fatal car accident 12 years after discharge. If the doctor writes a medical nexus letter without this context, then VA would probably reject it outright.
VA Disability Nexus Letter for PTSD: What if the doctor is not 100% sure?
While the burden is on the veteran to prove his claim, the standard of proof is much lower than in criminal or civil cases. A VA disability nexus letter for PTSD does not need to express 100% certainty. It does not even need to be beyond a reasonable doubt. If your doctor finds there is at least a 50/50 chance that your disability is related to service, then that is enough to win. In other words, a good medical nexus letter states that it is “at least as likely as not” that the disability is related to service. Of course, if your doctor believes it is more likely than not, then this only strengthens the nexus letter. The more context a veteran provides, the more certain a doctor can be of the relationship to service.
VA Disability Nexus Letter for PTSD: How did you get to your conclusion?
Most of the value of a medical nexus letter comes from its reasoning. If it only contains data and conclusions, then VA will reject it. A nexus letter that merely lists the evidence reviewed without explaining why it led to the conclusion has no value. At a minimum, the explanation must allow VA to conclude that the doctor applied valid medical analysis to the facts pf the case.
Example of a VA Disability Nexus Letter for PTSD
Let’s say you are seeking a medical nexus letter for PTSD. For the past 5 years, you’ve seen a psychiatrist for regular treatment. After the doctor agrees to help, you give him full access to your military and civilian medical records. During his review, the doctor notes that you had in-service medical treatment for symptoms of PTSD. The doctor also notes that the PTSD was diagnosed less than 2 years after service. After reviewing medical literature, the doctor agrees that “it is at least as likely as not that” your PTSD is related to your military service. His medical nexus letter should explain why the in-service symptoms and the post-service diagnosis matters. It should also cite any medical literature that supports his opinion. This would be a very strong medical nexus letter for PTSD.
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Can I get TDIU for PTSD? Yes. TDIU is a special benefit for veterans who cannot support themselves due to service-connected disabilities. It pays the same as a 100% rated disability. For TDIU to apply, your PTSD must first be service-connected. This may seem simple, but several veterans have PTSD because of a traumatic event that happened years after military service. Second, you cannot earn a living because of PTSD.
TDIU for PTSD Requirements
In order to be granted TDIU for PTSD is does not mean the veteran has to be unemployed. VA will grant TDIU to an employed veteran if the employment is considered marginal. VA deems employment marginal if the veteran earns LESS than the federal poverty threshold for one person (in 2018, $12,784.00 per the U.S. Census Bureau).
Rating Percentage
The veteran must meet the percentage requirements. If the veteran has only one service-connected disability, it must be rated 60% or higher. The Schedule of Ratings for PTSD permits only the following ratings: 0%, 10%, 30%, 50%, 70% and 100%.
Services Connected Disabilities
If the veteran is only service-connected for PTSD, it must be rated no lower than 70% to get TDIU. However, if the veteran has more than one service-connected disability, then at least one must be rated 40% or higher. Also, there must be “sufficient additional disability to bring the combined rating” to 70% or higher.
FREE CASE REVIEW, CLICK HERE, or Call 1-800-700-0652.
Disability Help Group Case Studies
Case Study 1: TDIU for PTSD
A 60 year-old veteran was diagnosed with PTSD secondary to his service-connected hypertension. VA previously awarded 10% for his hypertension. In March 2018, the Board of Veterans’ Appeals denied his PTSD claim. After a successful appeal, DHG secured a remand for a new VA medical examination. In November 2019, VA granted service connection for PTSD at 70% effective September 2009. Because the evidence showed that his PTSD prevented him from working, VA also granted entitlement to TDIU. He received a lump sum of $340,000.00, and his monthly payment changed from $133.57 to $3,057.13.
Case Study 2: TDIU for PTSD
A 65 year-old veteran asked VA for a higher rating for his PTSD. At the time, he was service-connected for tension headaches at 50% and PTSD at 50%. His combined rating was 80% and he had not worked since 2012. After a successful appeal, VA granted TDIU back to 2012. As a result, he received a lump sum of $121,000.00, and his monthly payment changed from $1,556.13 to $3,057.13.
Case Study 3: TDIU for PTSD
A 65 year-old veteran had a 50% rating for anxiety with PTSD and a 10% rating for a lumbar spine condition. Shortly after he hired Disability Help Group, it was clear that VA should have granted at least a 70% rating for anxiety with PTSD. After a successful appeal, VA granted a 70% rating for PTSD and then granted TDIU. He received a lump sum of $109,000.00, and his monthly payment changed from $1,062.27 to $3,057.13.
While most of this article refers to PTSD, it also applies to other mental disorders. For example, many of our clients have won TDIU based on their service-connected schizophrenia.
What is VA Permanent and Total Disability? The Department of Veterans Affairs (VA) offers 2 disability benefit programs: 1) Compensation; and 2) Pension. Both disability programs provide monthly payments to disabled veterans. There is a major difference in the programs.
VA Pension Total and Permanent
VA Pension is a needs-based program similar to Social Security’s Supplemental Security Income (SSI). Similarly to SSI, to be eligible for pension benefits, a veteran must have wartime service, low income, and a Permanent and Total disability. The Permanent and Total disability does not need to be “connected” to the period of military service. Disabled veterans aged 65 years or older can receive Permanent and Total disability for pension. For further information on Permanent and Total disability you can read our blog, How Can I Get TDIU.
VA Compensation Total and Permanent
VA Compensation is not based on need, income or age. It pays a veteran for disabilities incurred in or aggravated during their active duty service. The monthly payment depend on how much the veteran’s ability to work is impacted.
Eligibility for VA Permanent and Total Disability
A veteran can be eligible for both Pension and Compensation. Generally, Compensation will pay more money per month than Pension. Many veterans seek Permanent & Total disability for Compensation purposes instead of Pension because it pays more money.
Can You Receive Total Disability without Permanent Disability?
VA will award Permanent and Total disability to veterans whose disabilities are rated 100% with a very low likelihood of improvement. Although the terms “Permanent” and “Total” are often discussed together, it is possible to have a permanent disability that is not totally disabling. For example, a veteran may have a PTSD permanent disability at 70%. The PTSD is not “Total” because it is less than 100%.
It is possible to have a total disability that is not permanent. For example, the same veteran’s PTSD may be temporary at 100% during hospitalization for a suicide attempt. To learn more about TDIU and PTSD you can read our posts, Can I get TDIU from PTSD? or VA Permanent and Total Disability for PTSD.
General Rule
Generally, VA will award a Permanent & Total designation
if the following criteria are met:
The veteran has a disability rated at 100%, and
Medical evidence shows that this disability is
not likely to improve during the veteran’s lifetime.
Medical Evidence
Your treating doctor can provide the best medical evidence to prove entitlement to Permanent and Total Disability. Ask your doctor whether your 100% disability is likely to improve during your lifetime. If the answer is no. Ask your doctor to put this opinion in writing. VA will most likely defer to your doctor’s opinion and award Permanent and Total disability.
Exception to the Rule
As with most rules, there are exceptions. Regardless of the percentage, VA will deem certain disabilities Permanent & Total. Examples include the loss or loss of use of both hands, both feet, or sight in both eyes. In addition, VA would probably award Special Monthly Compensation.
Case Studies
The following DHG clients received a Permanent & Total disability rating.
PTSD Permanent and Total Disability
A 50 year-old Gulf War combat veteran filed a claim for PTSD in 2009. In 2010, he was denied despite the Combat Action Ribbon noted on his DD Form 214. After significant development, we won the case on appeal. The medical evidence proved that he met the criteria for a 100% rating. His symptoms included unprovoked irritability with periods of violence, impaired impulse control, audio hallucinations, and panic attacks. They were so severe that he could not hold a job. In addition, his doctor wrote that his symptoms would only get worse throughout his lifetime. VA awarded a Permanent and Total disability for PTSD. You can also work and get TDIU, if you are working you may want to read our post, Can I Work and Get TDIU?
Schizoaffective Disorder
A 57 year-old Air Force veteran lost his wife to a deadly car accident. This happened 3 months into his active duty service. He was never the same after that accident. He was diagnosed with schizoaffective disorder, depressive type. Unfortunately, he turned to drugs and alcohol to self-medicate his symptoms. He was homeless for many years. When he filed a compensation claim, VA branded him a drug addict. At the local VA hospital, he met another veteran who referred him to us. We developed medical evidence, a lay statement from the veteran, and legal arguments. Our represtative also submitted a medical opinion from a private psychiatrist, who recommended a total and permanent rating based on the medical evidence. Shortly afterwards, VA awarded a Permanent and Total disability rating for schizoaffective disorder
Call for a Free Case Review
When VA awards a Permanent and Total disability rating your rating is protected for the rest of your life. Are you eligible for Permanent & Total disability.
For a FREE CASE REVIEW, Call 800-800-3332 or click here.
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