THE CLAIMS PROCESS. Jim Richards Casey Matuszak Don Hubbard

Transcription

1 THE CLAIMS PROCESS Jim Richards Casey Matuszak Don Hubbard 1

2 OBJECTIVES 1. Understand the elements of the claims process. The Interview Evidence Examination Rating Appeal 2

3 OBJECTIVES 2. Establish a structure to insure quality. 3. Identify individual strengths and weaknesses. 3

4 METHOD Role-playing Scenarios Interaction between Instructors & Students Interaction between Students 4

5 THE INTERVIEW 5

6 THE INTERVIEW Importance Know the claimant Judge credibility ID issues and evidence Communicate needs of both parties Gain trust 6

7 Guidelines for Conducting Interviews M21-1MR II 4 Begin the interview as promptly as possible Control the interview Be courteous, objective, and empathetic to the customer. Provide thorough and accurate information Gather sufficient information to answer questions, and develop any issues 7

8 Guidelines for Conducting Interviews M21-1MR II.4 Avoid using technical jargon/acronyms. Do not allow interruptions. Discuss any related VA or non-va benefits with the interviewee. secondary conditions state and VHA benefits Never promise something that can t t or may not be done. 8

9 THE INTERVIEW What went well? 9

10 THE INTERVIEW ISSUES 10

11 THE INTERVIEW What was missing? 11

12 THE INTERVIEW ISSUES 12

13 THE EVIDENCE 13

14 THE EVIDENCE Competent medical evidence (38 CFR (a)(1)) means: evidence provided by one who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. statements conveying sound medical principles found in medical treatises. Statements contained in authoritative writings such as medical and scientific articles 14

15 THE EVIDENCE 38 CFR 3.159(a)(2) Competent lay evidence means: evidence not requiring that the proponent have specialized education, training, or experience. evidence provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person 15

16 THE EVIDENCE DTA letter with VCAA Buddy statement IED & Back Lay statement back symptoms Private medical evidence 16

17 THE EXAMINATION 17

18 THE EXAMINATION Is it adequate? Clinician s s Guide Issues covered Medical Opinion 18

19 THE RATING 19

20 THE RATING Issues Listing of evidence submitted VA examination VA medical records Reasons & Basis Effective dates Percentages Ancillary benefits 20

21 THE RATING Group breakouts Review assigned issues Review more if possible Select a leader to present 21

22 THE RATING 1. Bilateral Hearing Loss 2. Tinnitus 3. SFW, Rt Arm, w/tender scar 4. SFW, Lt arm w/rfb 5. PTSD 22

23 THE RATING 6. Back Condition 7. DM II 8. Lt Toe Amputation 9. ED 10. Heart Condition, Assume AO Presumptive effective - May 1,

24 THE RATING 1. Bilateral Hearing Loss Percentage? Effective Date? 24

25 THE RATING 2. Tinnitus Percentage? Effective Date? 25

26 THE RATING 3. SFW, Rt Arm, W/Tender Scar Percentage? Effective Date? 26

27 THE RATING 4. SFW, Lt Arm W/RFB Percentage? Effective Date? 27

28 THE RATING 5. PTSD Percentage? Effective Date? 28

29 THE RATING 6. Back Percentage? Effective Date? 29

30 THE RATING 7. Diabetes Percentage? & Effective Date? 30

31 THE RATING 8. Erectile Dysfunction Percentage? Effective Date? 31

32 THE RATING 9. Left Toe Amputation Percentage? Effective Date? 32

33 THE RATING 10. Heart Condition Percentage? Effective date? 33

34 THE RATING SMC 34

35 POST DECISION Vet calls up on 2/1/2011, four months after the decision, and says he is not happy with 10% for PTSD. He is having increased problems with anger issues, flashbacks and some social isolation. He hasn t t been to a VA MD in the last 6 months. 35

36 POST DECISION What choices does the NSO and Vet have? 1. Reconsideration During appellate period New & material evidence (38 CFR ) 2. Delay the claim pending treatment 3. Notice of Disagreement (NOD) 36

37 THE APPEAL 37

38 THE APPEAL Notice of Disagreement Requirements (38 CFR & ) Should the vet write his own NOD? Best NOD? 38

39 THE APPEAL Vet wants to file a NOD on his back as he thinks it should be more. The back is a solid 10%. What do you do? Does the vet have a legal right to file a NOD? Does the vet have a legal right to have MOPH file the NOD? 39

40 THE APPEAL MOPH POLICY MOPH POLICY MOPH does not require NSOs to represent every claimant. Rather, the policy requires NSOs to accept claims that have a reasonable chance of success. Therefore, it is up to the NSO to determine whether or not to take the claim. (P&P Manual Sec. II P) 40

41 THE APPEAL FRIVOLOUS CLAIM 38 USC 5904 (b) Suspension of Agents and Attorneys. The Secretary.may suspend or exclude from further practice..any agent or attorney..if the Secretary finds that such agent or attorney (6) has presented to the Secretary a frivolous claim, issue, or argument, involving conduct inconsistent with ethical standards for the practice of law; 41

42 THE APPEAL FORM 9 (38 CFR & ) Review C File Hearing or No Hearing (38 CFR ) DRO vs. BVA Written rebuttal 646 Note Key issues 42

43 THE APPEAL STAGED RATING separate ratings can be assigned for separate periods of time based on facts found 38 CFR (a) BVA AMC or RO on Remand 43

44 THE APPEAL STAGED RATING Best Defense Continuous submission of current medical evidence, VA & PMD Request new VAE if disability increased in severity during the appeal. 44

45 MISCELLANEOUS PRIVACY ACT Mrs. Vet calls and states her husband is on the road and wants to know if the percentages are correct and wants to know his current rates with the COLA on 12/1/10. What do we do? VA Regulation Privacy Act (38 CFR ) 526) Monetary benefit 38 CFR 3.502) MOPH Release of Information VA Release of Information 45

46 MISCELLANEOUS MOPH Release of Information P&P Manual Sec II Q I hereby authorize the MOPH National Service Officer to discuss my VA claim with, who is my. This permission includes information contained in my VA, military and medical records. Final decisions about whether to pursue or withdraw a claim or issue can only be made by me. This authorization will continue until I inform MOPH of its cancellation in writing. Name: Date: 46

47 MISCELLANEOUS Apportionment Claims MOPH Policy The MOPH Mission is to assist Veterans, their widows, and orphan children. We will not be involved in domestic disputes against veterans. Therefore, we will not routinely accept a Power of Attorney (POA) from a non-veteran for the purpose of filing an apportionment claim against a veteran. Exception: An NSO may accept a POA from a veteran who files an apportionment claim against his/her spouse. 47

48 MISCELLANEOUS CRSC/CRDP Joe vet calls up as he heard about CRSC and CRDP, Wants to know what to do. His military retirement is $800.00/month. Began on 60th birthday, 5/1/2010. What now? 48

49 MISCELLANEOUS CRSC Retired soldiers benefit program > 20 yrs Chapter 61; < 20 years service Combat Rated Injury/illness SW Simulation Simulation HS Hazardous Hazardous service IN Instrument Instrument of war AC Actual Actual combat 49

50 MISCELLANEOUS CRSC Apply to respective service Receipt of VA Compensation Receipt of retired pay Rating of 10% > Retired 20 years > Medical retire < 20 years Guard/Reserve 20 years > 50

51 MISCELLANEOUS CRDP Retired pay & VA compensation Service related 2014 Phase in 50% Retired 20 years or > 51

52 Concurrent receipt Example: 50% Rating MISCELLANEOUS CRSC YES CRDP NO 10 YR PHASE $690 $403 Required min rating 10% 50% Taxable VA IU eligible Application Required Type of Disability Survivor Benefit NO YES YES-DD 2860 Combat Related NO YES 3 YR PHASE NO- AUTOMATIC Service Connected NO 52

53 CONCLUSION 1. Reviewed the elements of the claims process. The Interview Evidence Examination Rating Appeal 53

54 CONCLUSION 2. Established a structure to insure quality. 3. Identified individual strengths and weaknesses. 54

55 WHY WE ARE HERE 55