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 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 but can also include free or low-cost mental health treatment and other healthcare; vocational rehabilitation services; employment assistance; independent living support; and more.
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.
Video Veterans benefits for post-traumatic stress disorder in the United States
U.S. veterans benefits
History
Since the founding of the country, the United States has sought to compensate the men and women who have served in its armed forces. 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. 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. Since OIF/OEF, PTSD has grown to be the third most compensated disability in the VA after hearing loss and tinnitus.
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, 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. 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 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.
Research indicates that veterans receiving disability benefits for PTSD experience a reduction in PTSD symptom severity, and have lower rates of poverty and homelessness.
In addition to lost income, a Congressionally-mandated commission, 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.
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, while other researchers take issue with this assertion. 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.
Maps Veterans benefits for post-traumatic stress disorder in the United States
VA disability claims process
To begin the disability claim process, veterans submit a claim to the Veterans Benefits Administration (VBA), an organizational element of the VA. In order for a veteran to receive disability benefits for PTSD, 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), which is a forensic mental health evaluation 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 VA Form 21-526, Veterans Application for Compensation and/or Pension, or online using eBenefits, an online portal for several VA benefits and health care services.
Benefits claim procedures
The VA provides a detailed description of the benefits claims process on its website. Briefly, a VSR (Veterans Service Representative), an employee of the Veterans Benefits Administration (VBA), reviews the information submitted by a veteran to determine if VBA needs any additional evidence (e.g., medical records) to adjudicate the claim.
VA has a legal obligation to help veterans obtain any evidence that will support their claim. For example, the VSR might request a veteran's military personnel records, Social Security disability records, or private medical records. As noted above, the VSR will usually request a Compensation and Pension examination (C&P exam), also referred to as a VA claim exam.
After VBA obtains all relevant documentation (evidence), an RVSR (Ratings Veterans Service Representative) renders a decision regarding the veteran's claim. The RVSR refers in part to the General Rating Formula for Mental Disorders when making this determination.
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", especially when they are affiliated with a nonprofit Veterans Service Organization. The veteran does not have to 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.
Although some veterans advocates recommend 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" (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, because a majority of the states have set up local veterans affairs offices in each of the state's counties.
Veterans service officers associated with nonprofit veterans service organizations
Many not-for-profit veterans service organizations 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.
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. 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:
(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.
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."
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 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.
The VA assigns disability ratings for PTSD according to the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130), 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." 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.
Concern has been expressed by some RSVRs (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.
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.
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, 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, and they meet the eligibility requirements, then they may file a compensation claim based on unemployability using VA Form 21-8940.
PTSD C&P exam
As noted above, the VBA almost always requires a compensation and pension examination (C&P exam), also known as a VA claim 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. However, note that the definition of "VA psychologist or psychiatrist" includes psychologists and psychiatrists in the private sector who conduct C&P exams for a Medical Disability Evaluation (MDE) company under contract with the Veterans Benefits Administration (VBA) to provide C&P exam services on behalf of the VA. Although litigation ensued after award of the initial $6.8 billion MDE contracts in 2016, pending any further appeals, the companies with current VBA contracts are Veterans Evaluation Services (VES), QTC, Medical Support Los Angeles, A Medical Corporation (MSLA), and VetFed.
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.
Researchers, current and former VA psychologists, investigative journalists, and individual veterans 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.
- 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.
- Research has demonstrated marked regional variance with regard to the proportion of veteran claimants who receive VA disability compensation for PTSD.
- One survey of C&P psychologists revealed that only 15% followed VA's own guidance regarding best practices for PTSD compensation and pension exams. For example, one of the best practice recommendations is to assess veterans for PTSD using the 'gold standard' Clinician-Administered PTSD Scale (CAPS), but the vast majority of C&P psychologists do not use this validated instrument according to the survey.
- An empirical study published in 2017 suggested C&P examiner racial bias might have led to a significantly increased rate of false negative conclusions (regarding PTSD diagnosis and service connection) for Black veterans, and a high rate of false positive conclusions for White veterans. This finding corresponds with past research and legal scholarship discussing the potential for implicit racial biases on the part of mental health clinicians in general, and C&P psychologists and psychiatrists in particular.
- Some VA facilities prohibit examiners from using symptom validity tests to screen or assess for malingering and other forms of dissimulation.
- Several researchers have published empirical studies in peer-reviewed scholarly journals pointing to significant rates of both false positive and false negative PTSD C&P exam conclusions.
- Social scientists conducted independent PTSD assessments of veterans who had filed disability benefits claims for PTSD, some of whom had been awarded service-connected compensation for PTSD and some had not. The study found significant rates of both false positive and false negative VBA adjudicative decisions. Although VBA adjudicators rely on other sources of evidence, in addition to C&P exam results, VBA almost always requests a C&P exam for PTSD claims, and C&P exam results significantly influence VBA determinations.
- Investigative journalists' reports, newspaper editorials, and individual combat veterans, assert that a sizable 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). 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. However, it is important to note that the VA discourages their mental health clinicians from completing DBQs for their patients, and similar recommendations have been offered to private psychologists and psychiatrists whose patients ask them to complete DBQs, because it potentially creates a conflict of interest due to a dual role relationship (serving simultaneously as a treating clinician and a forensic evaluator).
C&P psychologists have expressed concern that the DBQ "Symptom List" (Section II, Number 5 on the Initial PTSD DBQ; Section VII on the Review PTSD DBQ; and Section III on the Mental Disorders DBQ) contains a series of signs, symptoms, and descriptions of functional impairment without any guidance regarding when these items should be endorsed. 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.
Important definitions
Discharge status
In order to be eligible for VA benefits, a veteran must have been discharged under other than dishonorable conditions. 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.
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."
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.
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.
Relevant regulations, e.g., 38 C.F.R. § 4.125(a), were updated on 4 August 2014 to reflect the publication of DSM-5. With the exception of cases filed or appealed before this change, VA psychologists or psychiatrists use DSM-5 when diagnosing veterans' mental disorders.
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.
The official definition in the Code of Federal Regulations 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.
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.
Types of military service
The regulations describe three categories of military service, active duty, active duty for training, and inactive duty training. Eligibility for VA disability compensation requires that the veteran's service occurred during one of these three categories. 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."
Notes
References
External links
U.S. Department of Veterans Affairs benefits information
- Federal Benefits for Veterans, Dependents, & Survivors
- Apply for Benefits Online
- VA Benefits in Brief
- Compensation and Pension Service
- VA Healthcare Benefits Overview
- Veterans Health Benefits Guide
- Online VA Healthcare Eligibility Check
Other veterans benefits resources
- The American Veterans and Service Members Survival Guide
- Overview of Benefit Claims Legal Process
- National Resource Directory - List of Veterans Service Organizations
U.S. government resources for military personnel and veterans
- MakeTheConnection.net
- Make the Connection Resources Search Engine
- National Resource Directory
PTSD treatment resources for veterans
- Information & Resources About PTSD
- Where to get help for PTSD
- Understanding PTSD
- PTSD Treatment Programs in the US Department of Veterans Affairs
- My HealtheVet: The Gateway to Veteran Health and Wellness
- Operation Warrior Wellness: Overcoming PTSD
- Military Sexual Trauma Resources Provided by the VA
- Military Sexual Trauma Resources for Women Provided by Stateside Legal-->
Source of the article : Wikipedia
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