Chapter 18

Navigating the VA Claims Process

Introduction to the VA Claims Process

Successfully navigating the VA claims process requires understanding both the formal procedures and the practical strategies that increase your chances of approval. This chapter provides a comprehensive guide to filing and pursuing secondary service connection claims through the VA system, with emphasis on the unique aspects of secondary claims.

Key Concepts

Effective navigation of the VA claims process for secondary conditions requires:

Understanding the specific requirements for secondary service connection claims
Knowing how to properly file claims through various submission methods
Preparing effectively for VA examinations
Responding appropriately to VA decisions
Utilizing available resources and assistance throughout the process

This chapter walks you through each stage of the claims process, from initial preparation to final decision, with specific guidance for secondary condition claims and strategies to overcome common obstacles.

Preparing to File Your Secondary Claim

Thorough preparation before filing significantly increases your chances of success. This section covers essential pre-filing steps for secondary claims.

Confirming Eligibility Requirements

Before filing, verify that you meet the basic requirements for a secondary claim:

Established service connection: Confirm that your primary condition is already service-connected
Current diagnosis: Ensure you have a formal diagnosis of your secondary condition
Medical nexus: Assess whether you have or can obtain evidence linking the conditions
Proper documentation: Verify you have access to necessary medical records
Timing considerations: Determine if there are any relevant deadlines or timing issues

Strategy: Review your VA eFolder or claims file to confirm the exact status of your primary condition, including the specific diagnostic code and current rating percentage. This information will be important when filing your secondary claim.

Gathering and Organizing Evidence

Compile and organize your evidence before filing:

Create an evidence inventory: List all available evidence supporting your claim
Identify evidence gaps: Determine what additional documentation you need
Obtain outstanding records: Request any missing medical records
Secure medical opinions: Arrange for necessary nexus opinions
Prepare personal statements: Draft your statement and request supporting statements
Organize chronologically: Arrange evidence to show the progression of your conditions
Make copies: Create duplicate sets of all documentation

Strategy: Create a cover sheet for each piece of evidence that briefly explains its relevance to your secondary claim. For example: “Dr. Smith’s treatment notes from January 15, 2023 (pages 3-4) document that my knee pain causes altered gait, which directly contributes to my hip condition.”

Deciding When to File

Strategic timing can affect your claim’s success:

Evidence readiness: File when you have sufficient evidence to support the connection
Medical stability: Consider whether your condition has stabilized
Treatment completion: Determine if ongoing treatments might provide additional evidence
Effective date considerations: Understand how filing date affects potential retroactive benefits
Intent to File: Consider submitting an Intent to File to preserve your effective date while gathering evidence

Using Intent to File

If you need more time to gather evidence but want to establish an earlier effective date for benefits, consider submitting an Intent to File (VA Form 21-0966). This preserves your effective date for up to one year while you gather the evidence needed for a complete claim. You can submit an Intent to File through:

VA.gov online submission
Calling the VA at 1-800-827-1000
Working with an accredited representative
Submitting the form by mail

After submitting an Intent to File, you have one year to submit your complete claim while maintaining the earlier effective date.

Seeking Professional Assistance

Consider obtaining help with your claim:

Veterans Service Organizations (VSOs): Organizations like the American Legion, VFW, DAV, and others provide free representation
Accredited Claims Agents: Non-attorney professionals accredited by VA to assist with claims
Veterans Law Attorneys: Lawyers specializing in VA claims (typically work on contingency for appeals)
VA-Certified Counselors: Can provide guidance at VA regional offices
Peer Support Specialists: Veterans who can help navigate the system

Strategy: For complex secondary claims, professional representation can be particularly valuable. Representatives understand the nuances of secondary service connection requirements and can help frame your evidence effectively.

Case Study: Effective Pre-Filing Preparation

A veteran with service-connected diabetes mellitus wanted to file a claim for peripheral neuropathy as a secondary condition. Before filing, he took these preparatory steps:

Reviewed his VA records to confirm his diabetes was service-connected at 40% and noted the exact diagnostic code (7913)
Scheduled an appointment with a neurologist, explaining he needed documentation for a VA claim
Underwent nerve conduction studies that confirmed peripheral neuropathy
Requested and received a detailed nexus letter from his neurologist explaining how his diabetes caused the neuropathy
Created a timeline showing:
- Diabetes diagnosis: March 2018
- Service connection for diabetes: September 2018
- First symptoms of numbness and tingling: April 2020
- Progression of neuropathy symptoms: April 2020 – present
- Formal neuropathy diagnosis: January 2023
Wrote a detailed personal statement describing how his diabetes led to neuropathy symptoms
Obtained a supporting statement from his wife documenting her observations of his symptoms
Compiled relevant medical literature on diabetic neuropathy
Organized all evidence chronologically with a table of contents
Consulted with a VSO representative who reviewed his evidence and helped prepare his claim

This thorough preparation resulted in approval of his secondary claim on initial review, without the need for a VA examination, because the evidence clearly established both the diagnosis and the connection to his service-connected diabetes.

Filing Your Secondary Claim

The actual filing process requires attention to detail and strategic choices. This section covers the mechanics of submitting your secondary claim.

Choosing the Right Form

Select the appropriate form based on your specific situation:

VA Form 21-526EZ: Application for Disability Compensation and Related Compensation Benefits
- Use for new secondary condition claims
- Use when you have never filed for the specific secondary condition before
VA Form 20-0995: Decision Review Request: Supplemental Claim
- Use when reopening a previously denied secondary condition claim
- Requires “new and relevant evidence”
- Must be filed within one year of prior decision for continuous pursuit
VA Form 21-4138: Statement in Support of Claim
- Use to submit personal statements and additional evidence
- Not a claim form itself, but supports your main claim form

Strategy: When in doubt about which form to use, consult with a VSO or call the VA directly at 1-800-827-1000 for guidance.

Completing Form 21-526EZ for Secondary Claims

Pay special attention to these sections when filing for a secondary condition:

Section I: Complete all personal information accurately
Section II: Check “New Claim” if this is your first time claiming this secondary condition
Section VIII: List your secondary condition with these key elements:
- Specify the exact diagnosis of your secondary condition
- Clearly indicate it is “SECONDARY TO” your service-connected condition
- Include the date your secondary condition began
- Example: “Peripheral Neuropathy of bilateral lower extremities SECONDARY TO service-connected Diabetes Mellitus Type II”
Section IX: List all relevant medical providers who have treated either condition
Section X: Identify any relevant records from non-VA facilities
Section XI: Complete if you’re submitting additional evidence

Clearly Identifying Secondary Claims

The most common filing mistake for secondary claims is failing to clearly identify the condition as secondary. Always use the specific phrase “SECONDARY TO” in your claim. For example:

Incorrect: “Depression”
Correct: “Depression SECONDARY TO service-connected chronic back pain”

This clear identification helps ensure your claim is properly processed as a secondary connection claim rather than as a direct service connection claim.

Submission Methods

Choose the submission method that works best for your situation:

Method	Advantages	Disadvantages
Online through VA.gov	Immediate confirmation Faster processing Digital tracking Can upload evidence directly	Requires computer access and skills File size limitations for uploads Less personal assistance
Through a VSO representative	Professional guidance Review before submission Help with evidence organization Ongoing claim support	Depends on representative availability May take longer to submit Quality varies by representative
By mail	No technology required Can submit large evidence packages Familiar process for many	Slowest processing time Risk of lost documents No immediate confirmation Harder to track
In person at VA regional office	Personal assistance available Immediate date stamp Questions answered directly	Requires travel to VA office Limited by office hours May involve wait times

Strategy: For complex secondary claims with substantial evidence, consider using a VSO to submit your claim. They can review your submission for completeness and help ensure your secondary relationship is properly identified.

Submitting Evidence

Follow these best practices when submitting evidence with your claim:

Submit evidence with initial claim when possible rather than waiting
Include a cover letter explaining what you’re submitting and why
Create an evidence list itemizing all submitted documents
Highlight key passages in lengthy medical records
Organize chronologically or by evidence type
Include page numbers for easy reference
Keep copies of everything you submit
Request confirmation of receipt when possible

Case Study: Effective Claim Submission

A veteran with service-connected PTSD wanted to file for hypertension as a secondary condition. He took these steps to submit an effective claim:

Completed VA Form 21-526EZ, clearly listing “Hypertension SECONDARY TO service-connected Post-Traumatic Stress Disorder (PTSD)”
Prepared a cover letter explaining:
- His PTSD was service-connected at 70%
- He was diagnosed with hypertension two years after his PTSD diagnosis
- Medical research supports a connection between PTSD and hypertension
- His cardiologist provided a nexus opinion supporting the connection
Created an evidence package including:
- A detailed evidence map showing how each document supported his claim
- His cardiologist’s nexus letter
- Blood pressure readings showing onset and progression after PTSD diagnosis
- Medical literature on PTSD and cardiovascular effects
- His personal statement describing stress-related blood pressure spikes
- A statement from his wife documenting her observations
Met with his VSO representative who:
- Reviewed his claim for completeness
- Suggested adding his VA mental health records showing PTSD severity
- Helped him submit the claim through the VSO’s direct submission system
- Provided him with confirmation of submission

This well-organized submission resulted in approval of his secondary claim within 90 days, with the rating decision specifically citing the strength of the evidence package in establishing the connection between his PTSD and hypertension.

Navigating the VA Examination Process

Compensation and Pension (C&P) examinations are a critical part of most secondary claims. This section provides strategies for effectively navigating this important step.

Understanding the C&P Examination

C&P examinations serve specific purposes in secondary claims:

Confirm current diagnosis of the secondary condition
Assess severity for rating purposes
Evaluate the relationship between primary and secondary conditions
Consider alternative causes for the secondary condition
Document functional limitations caused by the condition

Note: Not all claims require a C&P examination. If you submit comprehensive evidence, including a clear medical opinion establishing the secondary connection, the VA may grant your claim without an examination.

Preparing for Your Examination

Thorough preparation can significantly impact your examination outcome:

Review your medical records before the appointment
Create a symptom journal documenting recent symptoms and limitations
Prepare a written summary of how your primary condition affects your secondary condition
List medications for both conditions
Identify your worst days and how symptoms affect you then
Practice describing your symptoms clearly and specifically
Arrange transportation that accommodates your conditions
Consider bringing a witness who can observe the examination

The Importance of Honesty

During your C&P examination, honesty is essential. This means:

Don’t exaggerate your symptoms, but don’t minimize them either
Describe your condition on its worst days, not just how you feel on the examination day
If asked about good days, acknowledge them but explain their frequency and limitations
Answer questions directly and completely
If you don’t understand a question, ask for clarification
If you don’t know an answer, say so rather than guessing

Exaggeration can damage your credibility, while minimizing symptoms can lead to an inaccurate assessment of your condition’s severity.

During the Examination

Maximize the effectiveness of your examination by:

Arriving early to complete any paperwork
Bringing a list of questions you want to ask
Taking notes during or immediately after the examination
Describing the relationship between your conditions clearly
Explaining functional impacts in specific terms
Answering questions completely but staying focused on relevant information
Asking the examiner to explain any tests or procedures
Reporting pain or discomfort during any physical examination

Strategy: Focus particularly on explaining the connection between your primary and secondary conditions. For example: “My service-connected knee injury causes me to limp, which my orthopedist has explained puts additional stress on my hip. I notice that when my knee pain is worse and I limp more severely, my hip pain increases within 1-2 days.”

After the Examination

Take these important post-examination steps:

Document your experience immediately after the appointment
Note the examiner’s name and specialty
Record the duration of the examination
List all tests performed and questions asked
Document any concerns about how the examination was conducted
Request a copy of the examination report
Review the report for accuracy when received
Submit corrections if you find factual errors

Case Study: Effective C&P Examination Navigation

A veteran with service-connected lumbar strain was scheduled for a C&P examination for his claim of radiculopathy as a secondary condition. He prepared for and navigated the examination process effectively:

Before the examination:

Created a one-page summary of his condition including:
- Date of service-connected back injury
- When radicular symptoms began (shooting pain down left leg)
- How back movements trigger the radiating pain
- Current symptoms and limitations
Reviewed his recent MRI report showing disc protrusion at L4-L5
Kept a symptom journal for two weeks prior, documenting:
- Pain levels in both back and leg
- Activities that triggered radiating pain
- Sleep disruptions from symptoms
- Functional limitations
Asked his wife to accompany him as an observer

During the examination:

Provided his symptom summary to the examiner
Clearly described how specific movements of his back triggered the radiating leg pain
Demonstrated the limited range of motion before radicular symptoms began
Explained that his symptoms were moderate on examination day but described their severity on worse days
Answered questions about alternative causes (no prior leg injuries or conditions)
Described functional impacts: inability to sit more than 30 minutes, difficulty driving, and limitations in bending and lifting

After the examination:

Wrote detailed notes about the examination including:
- The examiner’s name and specialty (neurology)
- Examination duration (35 minutes)
- Tests performed (straight leg raise, reflexes, sensation testing)
- Questions asked about the relationship between conditions
- His responses to key questions
Requested a copy of the examination report through his eBenefits account
Reviewed the report when received and found it accurately documented the connection between his service-connected back condition and radiculopathy

Addressing Unfavorable Examination Results

If your examination results in an unfavorable opinion:

Request a copy of the examination report immediately
Review for factual errors that can be corrected
Identify any inadequacies in the examination process
Consider obtaining a private medical opinion to counter negative findings
Submit a statement addressing any inaccuracies or omissions
Consult with a representative about your options
Consider requesting another examination if the first was clearly inadequate

Strategy: If you receive an unfavorable examination report, focus on objective issues with the examination rather than simply disagreeing with the conclusion. For example, note if the examiner didn’t review critical medical records, spent insufficient time examining you, or made factual errors about your medical history.

Responding to VA Decisions

How you respond to the VA’s decision on your secondary claim can significantly impact your benefits. This section covers strategies for different decision outcomes.

Understanding Rating Decisions

When you receive a rating decision on your secondary claim, review it carefully for:

Service connection determination: Whether secondary service connection was granted
Effective date: When benefits begin if granted
Disability percentage: Rating assigned to the secondary condition
Combined rating: How the new rating affects your overall disability percentage
Reasoning provided: Explanation for the decision
Evidence considered: What documentation was reviewed
Appeal rights: Options if you disagree with the decision

If Your Claim Is Granted

If your secondary claim is approved, take these steps:

Verify the rating percentage is appropriate for your symptom severity
Confirm the effective date is correct based on your filing date
Check the combined rating calculation for accuracy
Review any additional entitlements that might apply
Consider whether the rating reflects the full impact of your condition
File for an increased rating if your condition worsens in the future
Update your healthcare providers about your service-connected status

Understanding Combined Ratings

The VA does not simply add percentages when calculating your overall disability rating. Instead, they use a combined ratings table that results in a lower total than simple addition. For example:

If you have a 40% rating for diabetes and receive a new 20% rating for peripheral neuropathy as a secondary condition, your combined rating will be 52%, which rounds to 50%, not 60%.
The VA first considers your highest rating, then calculates how much of your remaining capacity is affected by each additional condition.
You can use the combined ratings calculator on VA.gov or consult with a VSO to understand how a new secondary condition will affect your overall rating.

Understanding this system helps you set realistic expectations about how a secondary condition will affect your total disability rating and compensation.

If Your Claim Is Denied

If your secondary claim is denied, consider these response options:

Supplemental Claim: Submit new and relevant evidence
- Use VA Form 20-0995
- Must include evidence not previously considered
- File within one year to preserve effective date
- Best when you can obtain stronger medical evidence
Higher-Level Review: Request review by a senior adjudicator
- Use VA Form 20-0996
- No new evidence can be submitted
- Can request informal conference
- Best when you believe VA made an error in applying law or policy
Board Appeal: Appeal to Board of Veterans’ Appeals
- Use VA Form 10182
- Multiple options for evidence submission and hearings
- Longer processing time
- Best for complex cases or when other options have failed

Strategy: For denied secondary claims, a Supplemental Claim is often the most effective first response, as it allows you to address the specific reason for denial with new evidence. For example, if your claim was denied because the VA examiner found insufficient evidence of a causal relationship, you can submit a more detailed medical opinion specifically addressing that issue.

Understanding Common Denial Reasons

Secondary claims are typically denied for specific reasons that can be addressed in appeals:

Denial Reason	Effective Response Strategy
Insufficient medical nexus	Obtain a more detailed medical opinion specifically addressing causation Include medical literature supporting the connection Provide a more detailed personal statement about the relationship
Alternative cause identified	Obtain medical opinion addressing and ruling out the alternative cause Provide evidence showing condition began after primary condition Document absence of alternative risk factors
Inadequate current diagnosis	Obtain clear diagnostic evaluation from specialist Submit results of diagnostic testing Provide treatment records showing ongoing care for the condition
Incomplete evidence review	Request Higher-Level Review highlighting overlooked evidence Resubmit critical evidence with clear explanation of its significance Provide an evidence map showing what was missed
Procedural error	Request Higher-Level Review identifying the specific error Cite relevant regulations or policies that were misapplied Request correction of the error

Case Study: Effective Response to Denial

A veteran’s claim for sleep apnea secondary to PTSD was initially denied. The rating decision stated: “While the evidence shows you have been diagnosed with sleep apnea requiring CPAP therapy, the VA examiner opined that it is less likely than not caused by your service-connected PTSD because your BMI of 32 is a more likely cause of your sleep apnea.”

The veteran responded with a Supplemental Claim that effectively addressed this denial:

Obtained a detailed medical opinion from a sleep specialist that:
- Acknowledged obesity as a risk factor but explained it was not the sole cause in this case
- Cited research showing PTSD can cause sleep apnea independent of weight
- Explained the specific mechanisms by which PTSD affects sleep architecture
- Noted the veteran’s sleep apnea was more severe than typically seen with his level of obesity alone
- Documented that the veteran’s BMI had been stable for years before developing sleep apnea, which coincided with worsening PTSD symptoms
Submitted a new personal statement detailing:
- His weight history showing stable weight for 5 years before sleep apnea diagnosis
- The correlation between PTSD nightmares and witnessed apnea episodes
- How PTSD medications affected his sleep breathing
Included three recent medical studies specifically addressing the relationship between PTSD and sleep apnea independent of obesity
Provided a statement from his wife documenting her observations of the relationship between PTSD episodes and sleep breathing disturbances

This focused response directly addressed the specific reason for denial by acknowledging the obesity factor while providing compelling evidence that PTSD was nevertheless a causative factor in his sleep apnea. The Supplemental Claim was approved, with the new rating decision noting that the additional evidence established that the sleep apnea was at least as likely as not caused by both obesity and PTSD.

Utilizing Resources and Support

Navigating the VA claims process effectively often requires utilizing available resources and support systems. This section explores key resources for secondary claims.

Veterans Service Organizations (VSOs)

VSOs provide valuable assistance throughout the claims process:

Claims preparation: Help organizing evidence and completing forms
Claims submission: Direct submission capabilities
Claims tracking: Access to status information
Decision review: Assistance interpreting decisions
Appeals assistance: Help with appeals processes
Veterans advocacy: Representation at hearings

Strategy: Consider working with a VSO that has experience with your specific type of secondary claim. Some VSOs have representatives who specialize in certain medical conditions or claim types.

VA Resources

The VA offers several resources to assist with claims:

VA.gov: Online claim filing and tracking
VA Regional Offices: In-person assistance
VA Call Center: Phone support at 1-800-827-1000
VA Medical Centers: Access to medical records and treatment
Vet Centers: Counseling and referral services
VA Mobile Apps: Tools for health management and claim tracking

Legal Resources

Legal assistance can be valuable for complex or denied claims:

Veterans Law Attorneys: Specialized legal representation
Legal Aid Organizations: Free legal services for qualifying veterans
Law School Veterans Clinics: Pro bono assistance from law students supervised by attorneys
State Veterans Legal Services: State-specific legal resources
Bar Association Referrals: Connections to attorneys with veterans law experience

Note: Attorneys typically cannot charge fees for assistance with initial claims but may charge contingency fees (typically 20-33%) for work on appeals after an initial denial.

Medical Resources

Medical resources can help establish the secondary connection:

VA Healthcare System: Treatment and documentation
Private Specialists: Expert opinions on condition relationships
Independent Medical Examiners: Evaluations specifically for claims purposes
Medical Research Databases: Access to studies supporting condition relationships
Medical Libraries: Resources on condition connections
Veterans Health Libraries: Information on veterans’ health issues

Peer Support

Fellow veterans can provide valuable guidance and support:

Veterans Support Groups: Shared experiences and advice
Online Forums: Communities focused on VA claims
Social Media Groups: Connections with veterans with similar conditions
Veteran Mentors: One-on-one guidance from experienced veterans
Veteran Peer Specialists: Trained peer support

Strategy: While peer support can provide valuable insights and emotional support, always verify claims advice with official sources or accredited representatives.

Creating Your Support Team

For complex secondary claims, consider assembling a support team that might include:

An accredited VSO representative for claims guidance and submission
A medical specialist familiar with your conditions who can provide expert opinions
A primary care provider who can coordinate care and documentation
A veterans law attorney for consultation if appeals become necessary
A peer mentor who has successfully navigated a similar claim
Family members who can provide supporting statements and emotional support

Each team member brings different expertise and perspective to support your claim. Coordinate communication between team members when appropriate to ensure everyone understands their role in supporting your claim.

Conclusion

Successfully navigating the VA claims process for secondary conditions requires understanding the system, thorough preparation, strategic execution, and persistence. By following the guidance in this chapter, you can significantly increase your chances of a favorable outcome.

Remember these key principles:

Preparation is critical: Gather comprehensive evidence before filing
Clarity matters: Clearly identify your claim as secondary
Details count: Be specific and thorough in all documentation
Persistence pays off: If denied, understand why and address those specific issues
Support helps: Utilize available resources and assistance
Patience is necessary: The process takes time, but proper execution is worth the effort

The next chapter will explore strategies for appealing denied claims, providing additional tools for addressing challenges in the VA claims process.

Chapter 18: Navigating the VA Claims Process