Insurance Claims - Page 2

Many people come to me after they have had their claim denied, and they’re not sure whether or not ERISA law makes it worth fighting the decision of their insurance company. After all, if a big company has looked at all the facts and decided that there is no reason you should be getting benefits, how can you really argue with that? Isn’t it possible that they’re just right?

Sure, it’s possible. But what you have to remember is that insurers aren’t paying your medical bills and helping with your disability out of the kindness of their hearts. They are in a business, and for them to make money, they need to make it difficult for people to collect.

Before they even look at your specific case and examine the evidence, the insurance company is considering what they can use to deny you benefits. If you miss specific criteria – forget to dot an “I” or cross a “t” –that can be the end of your claim. Requesting an administrative appeal is your way to fight against this and give yourself a second chance.

Any disability claims for Agent Orange related diseases that were denied or filed after September 24, 1985, and before the list of diseases in Table 8-1 was published, could be considered Category 1 claims. In these cases, the rules that define what is considered to be an official disability compensation claim are very liberal.

Some examples of communications that should be sufficient to allow a veteran to qualify for the special Agent Orange effective date rules for disability compensation are:

Although most disability claims require that veterans provide medical evidence of the link between a current disability and a precipitating service incident, there are a few special circumstances for which evidence of nexus is not necessary. “Chronicity” refers to a situation in which a veteran can receive benefits because the disability in question is a chronic condition that was diagnosed during a period of service or a designated presumptive period.

If you feel that your disability could be considered chronic by the VA, you’ll need to provide medical evidence showing that you were diagnosed with the condition during service and that a recent medical examination found that you continue to suffer from the same condition. Though you will have to produce statements from medical professionals, you won’t need to present anything other than diagnoses – no need for the detailed medical opinions and analysis required for other VA disability claims. The direct service connection is presumed under the policy of chronicity.

Although the vast majority of veterans claims require medical proof of a link between a veteran’s current disability and a precipitating service incident, there are a few circumstances in which a medical opinion stating the link is not required.

Generally, if a veteran’s current disability is an obvious result of an injury occurred during service (such as missing leg amputated after a service incident), the veteran will not be required to provide a medical opinion proving the link and will be granted veterans benefits. In cases like this, “lay evidence” (evidence provided by someone without medical expertise) is sufficient for the VA to make a determination. As long as the disability in question is readily identifiable to someone without medical training, lay evidence will be all that is required for the VA’s favorable ruling.

You already know that to successfully argue veterans claims being considered eligible for veteran status requires that you served actively in one of the five branches of the military (or in several other military branches) and were discharged under circumstances that were other than dishonorable. But how are you supposed to prove all this to the VA Board? Though the standard of proof requires that the VA give you the benefit of the doubt if the evidence on both sides is equal, the burden is still on you to make a convincing case.

The VA’s decision is based mostly on service records, but you’re the one who has to compile and submit these documents. If you have any doubt about the requirements for making your case, consult a VA disability lawyer immediately.

The Active Service Requirements for a Veterans Disability claim must be met in order for a Veteran to receive most types of Disability Compensation benefits. The next step in the veterans claims process is establishing whether your service can be considered “active.” This step can be a little trickier than meeting the requirement for military service, so you may want to consider enlisting the help of a qualified disability attorney before embarking on your veterans claims application.

Denial of veterans’ claims is happening more and more with an overburdened and undertrained VA workforce. Because the claims adjudicators don’t understand how the veterans’ claims process works, many claims are incorrectly denied and end up being appealed and ultimately overturned. In some ways, this is good news for veterans, but if your VA claim is denied, it can lead to a lengthy and complicated appeals process where you need an experienced veterans benefits attorney on your side.