Fully Developed Claims
By
Tripp Cantwell
Department of Michigan
Objectives
• To describe The Fully Developed Claims (FDC) program
• To explain how to file both Formal and Informal FDC’s
• To explain the value of DBQ’s in the FDC process
• To explain Fast Letter 13-17 and the one year retro
requirements
1
National Performance
Based on national numbers as of June 1, 2014 for FY 2014:
•
•
•
•
Nearly 146K FDCs completed, with an average days to
complete (ADC) to date of 147.4
Nearly 38K FDCs that have been excluded from the
program with an ADC of 248.8
Nearly 682K non FDC claims (traditional claims)
completed with an ADC of 261.9
To date, there are nearly 864K total claims completed
with an ADC of 242.1
2
What is a Fully Developed Claim (FDC)?
• The Fully Developed Claims (FDC) program is an initiative that
offers Veterans and survivors faster decisions from VA on
compensation, pension, and survivor benefit claims.
• For an FDC, VA will
– Retrieve relevant records from a Federal facility, such as a
VA medical center when identified by a claimant
– Provide a medical examination, or get medical opinion, if
VA determines it is necessary to decide the claim
• VA will send a development letter to the claimant under the
FDC program only when:
- A claim for a condition has been previously denied
- VA determines that federal records are unavailable
3
What’s different about an FDC?
FDC Program
Standard Claim Process
• Provides claimants notice of the
evidence necessary to
substantiate a claim prior to
submission
• Provides claimants notice of
the evidence necessary to
substantiate a claim after a
claim is received
• Claimants submit all evidence
necessary to decide their claim at
the time of submission and
certify there is no additional
evidence
• Supporting evidence is
submitted after the claim is
filed
- Often awaiting evidence from
sources, e.g. private doctors
• Significant reduction in
processing time
• Longer processing times
4
FDC Exclusions (Traditional Claims)
• A few types of claims are not specifically covered by the FDC
notice. Examples include:
• Claims for Permanent & Total status
• Claims for Hepatitis C
• Claims for a higher level of SMC (i.e. R-2)
• Administrative Exclusions:
IE.. Needs non-Fed evidence development, Evidence received
after FDC is CEST’d, Claimant declined FDC processing, FDC
certification incomplete, Additional claim submitted, Claim
pending, Appeal pending, Necessary form(s) not submitted,
Failure To Report to exam
5
Submitting an FDC
• By filing one or more of the VA approved FDC forms:
• VA Form 21-526ez Fully Developed Claim (Compensation)
• VA Form 21-527ez Fully Developed Claim (Pension)
• VA Form 21-534ez Fully Developed Claim (Application for DIC,
Death Pension, and Accrued Benefits)
• Obtaining an eBenefits account to file online at
www.ebenefits.va.gov
Please note: The new forms are dated August 2013. Only the forms dated August 2013 or later
will be accepted into the FDC program .
6
Submitting an FDC
• A claimant must submit copies of Disability Benefit
Questionnaires (DBQ’s) or their private treatment records for
VA to consider in order to remain eligible for the FDC program
• Private medical evidence includes:
- Treatment notes from private physicians
- Hospital records, Outpatient records
- National Guard/Reserve records
- Any medical records related to the claimed disability
• Medical records alone typically will NOT replace the VA
examination requirement
If the claimant submits a completed VA Form 21-4142 for a
private provider the claim will be excluded from the FDC process
7
Disability Benefit Questionnaires
• DBQs are downloadable electronic forms that, once
completed by a private physician with an active medical
license, serve as the equivalent to an examination at a VA
facility
– DBQs can speed the Fully Developed Claims process by providing
medical information that is directly relevant to determining a disability
rating
– Claimant has the option of visiting a private health care provider to
complete these at their cost instead of waiting for an appointment at a
VA facility
• Submitting an appropriately completed DBQ(s) along with an
FDC can eliminate the need to attend a VA examination
8
What types of claims can be FDC?
1. Service connection (original, new, secondary, and reopened)
2. Service connection based on a period of active duty for training or inactive
duty training
3. Increased disability compensation
4. Individual Unemployability
5. Temporary total disability rating due to hospitalization or due to surgical or
other treatment
6. Compensation under 38 U.S.C. 1151
7. Increased benefits based on the need for aid and attendance or based on
an additional disability or housebound status (SMC)
8. Specially adapted housing or special home adaptation
9. Automobile allowance or adaptive equipment
10.Benefits based on a Veteran’s helpless/seriously disabled child
9
What types of claims can be FDC? (cont.)
11. Improved Pension
12. Special Monthly Pension (Aid and Attendance or housebound benefits)
13. Improved Pension benefits based on a Veteran’s helpless/seriously
disabled child
14. Accrued benefits
15. DIC based on service-connected cause of death
16. DIC based on 38 U.S.C. §1318
17. DIC based on active-duty-for-training or inactive-duty-training death
18. Survivor’s pension and Parents’ DIC
19. 38 U.S.C §1151 DIC
20. Increased survivor benefits (aid and attendance or housebound)
21. Benefits for a Veteran’s helpless/seriously disabled child
10
VA’s Duty to Assist
• The EZ forms provide notification required by 38 C.F.R§5103
at the time the claimant applies for benefits.
• Compensation claims (1-10 on the previous slide) MUST be
submitted on VA Form 21-526EZ
• Pension claims (11-13 on the previous slide) MUST be
submitted on VA Form 21-527EZ
• Survivor claims (13-21 on the previous slide) MUST be
submitted on VA Form 21-534EZ
• All 3 of these forms satisfy the DTA requirements of 38 C.F.R§5103
• All 3 of these forms can also be electronically completed and
submitted at www.ebenefits.va.gov
• Requirements for the submission of additional forms for
“Special Circumstances” are described in the next 3 slides
11
Application Special Circumstances
• Guard and Reserve members, must submit all service treatment and
personnel records in the custody of their Unit(s)
• If claiming dependents, must submit VA Form 21-686c, Declaration of
Status of Dependents (with ALL birth and marriage documentation)
• If claiming a child in school between ages of 18 and 23, must submit VA
Form 21-674, Request for Approval of School Attendance
• If claiming seriously disabled (helpless) child, must submit all relevant
medical records pertaining to the child’s disabilities before obtaining the
age of 18
• If claiming Post Traumatic Stress Disorder (PTSD), a completed VA Form
21-0781, Statement in Support of Claim for Service Connection for PTSD; if
claiming PTSD based on Personal Trauma, VA Form 21-0871a
12
Application Special Circumstances (cont.)
• If claiming Individual Unemployability (IU), a completed VA Form 218940, Veteran’s Application for Increased Compensation Based on
Unemployability, and a completed VA Form 21-4192, Request for
Employment Information in Connection with a Claim for Disability Benefits
• If claiming a Specially Adapted Housing or Special Home Adaptation, a
completed VA Form 26-4555, Application in Acquiring Specially Adapted
Housing or Special Home Adaptation
• If claiming Auto Allowance, a completed VA Form 21-4502, Application for
Automobile or Other Conveyance and Adaptive Equipment
• If claiming additional benefits because the Veteran or his/her spouse
requires Aid and Attendance, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and
Attendance, If claiming Aid and Attendance, based on nursing home
attendance, completed VA Form 0779, Request for Nursing Home
Information in Connection with Claim for Aid and Attendance
13
Application Special Circumstances (cont.)
• If claiming DIC as the parent of the Veteran, all necessary income and net
worth information and, if claimant benefits as the foster parent of the
Veteran, a completed VA Form 21-524, Statement of Claiming to Have
Stood in Relation of Parent
• Survivor Claims require the submission of the Veterans Death
Certificate (unless he/she died on active duty)
• Dual Compensation and Pension claims MUST be submitted
separately on VA Forms 21-526EZ and 21-527EZ
14
Exclusions from the FDC Program
• An applicant can be excluded from the FDC program for
various reasons, including:
• The claimant indicates he/she does not want VA to process his/her
claim under the FDC program
• The claimant has a claim pending at the time VA receives the EZ form
• The claimant has an appeal pending at the time VA receives the EZ
form and the claims folder is not located at the regional office (RO) of
jurisdiction
• The claimant fails to simultaneously submit any of the additional items
VA requires to process his/her specific claim
• Further evidence is needed from the claimant such as
•
-(a) private medical care provider(s), or
•
-records in the custody of the Veteran’s Guard/Reserve unit
15
Exclusions from the FDC Program
• The claim requires a character of discharge determination
• Completion of NA Form 13055, Request for Information
Needed to Reconstruct Medical Data, (by the claimant)
because his/her service treatment records were destroyed by
a fire at the National Personnel Records Center (NPRC) in 1973
• The Veteran fails to report for a VA examination and asks VA
to reschedule it (unless VA is solely at fault because it, for
example, did not provide the examining facility with the
claimant’s correct mailing address), or
• The Veteran submits another claim, additional evidence, or a
notice of disagreement after submitting the FDC
16
FDC Program Development
• The only development VA undertakes in connection with an
FDC is to request:
• A VA Examination
• To request Federal records in the custody of the Federal government
(This includes records in the custody of VA medical centers but
excludes records in the custody of a Veteran’s Reserve/Guard unit(s) or
records at NPRC that can only be obtained if the claimant completes
NA Form 13055), VA must undertake the development described in
M21-1MR, Part III, Subpart i, 3.B.6. and/or
• If a claimant submits an FDC in an effort to reopen a previously denied
claim, VA must undertake the development described in M21-1MR,
Part III, Subpart i, 3.B.7.
17
FDC Program Development (cont.)
• For both Federal Records and Reopened FDC’s when notifying
the claimant of the VA’s findings it should include the
following:
“We received your claim and your request to participate in the Fully Developed Claim (FDC)
Program. Though you indicated you have no other information or evidence to give VA to support
your claim, we are required to send you this notice. If you have information or evidence not
previously submitted to VA that supports your claim, we recommend you submit it. As a
reminder, if you submit any additional information or evidence at this point, VA will remove your
claim from the FDC Program Expedited Process and process it in the Standard Claim Process.”
• The VA will not wait for a response to the letter before
undertaking the development actions
• The VA will allow the claimant 30 days to respond to the
letter. If the claimant submits additional evidence, then the
claim is removed from the FDC program
18
FDC Program Development (cont.)
• When a claim is excluded from the FDC program, either at
initial receipt or subsequently, the claimant is notified using
language such as:
“We cannot process your claim under the Fully Developed Claim
Program because…
we received evidence requiring further
development after the claim was received.
you did not report for a scheduled VA examination.
you did not sign your FDC application.
19
Informal or Incomplete Claims
• To submit an Incomplete (online) or Informal claim, use VA
Form 21-4138 or a letter with the following statement:
“The American Legion as POA or as Next Friend of Claimant,
pursuant to 38 C.F.R. 3.155(a) on behalf of the claimant informs
the VA of the claimant’s intent to apply for compensation and/or
pension benefits under the FDC Program. This statement is to
preserve the effective date for entitlement to benefits. The
veteran’s date of birth is 10/19/1951.
Claimant understands they have one year to complete the claim
or they will lose the effective date of this claim.”
20
Informal or Incomplete Claims
• If a claimant identifies a specific contention (e.g., left leg,
diabetes, etc) the VA will consider it a formal application. It
will place the claim under end product control (e.g., EP 020)
effective the date of receipt of the communication, and it will
be moved forward for processing.
• Also if a claim is filed for one of the Special Circumstances
such as PTSD, Agent Orange exposure, Military Sexual Trauma
(MST), etc., and the claim is submitted without the proper
forms and further development from the claimant is needed,
then the claim must be removed from the FDC program
(ie..submitting a VA Form 21-4142)
21
One-year Retroactive Date
On August 6, 2012, the President signed a comprehensive
legislative package, the “Honoring America Veterans and
Caring for Camp Lejeune Families Act of 2012,” PL 112-154.
Section 506 of this Act amends 38 U.S.C.§5110 to allow up
to a one-year retroactive effective date for awards of
disability compensation based on fully developed original
claims.
August 2, 2013 Fast Letter 13-17 Processing Fully Developed
Original Claims Received from August 6, 2013 through August
5, 2015 further defined this benefit.
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Eligibility for the one-year retroactive date
• The claim must be compensation – no other types of claims
are eligible
• The claim must be original, an initial formal (complete) claim
filed by a Veteran or their representative
• The Veteran must have separated from his/her last period of
active duty service more than one year ago
• The claim must be received from August 6, 2013 through
August 5, 2015
• The claim must be received on a VA Form 21-526EZ. Veterans
can also apply through eBenefits using VONAPP Direct
Connect (VDC)
• If any of these requirements are not met, VA will determine if
the claim is still eligible for processing under the FDC program
23
Calculating the one-year retroactive date
The evidence of record must support the evaluation assigned
from the effective date.
For example; if evidence submitted with the FDC shows the
level of disability existed for one year prior to submission of
the claim, then process the award with a one-year retroactive
effective date.
If, however, the evidence of record supports less than oneyear of disability, process the award accordingly
Unless there is evidence clearly supporting a staged rating,
the rating should be consistent through the entire retroactive
period.
24
Calculating the one-year retroactive date
• Claimants are eligible to receive retroactive pay and an
effective date calculated as whichever is the earlier of
- the date up to one year prior to receipt of the complete
FDC if the facts support such an effective date, or
- the date of receipt of an informal claim for which a formal
(complete) FDC was subsequently received
• In either case, the effective date may not be more than one
year prior to the date the formal (complete) FDC claim is
received.
25
Calculating the one-year retroactive date
• If a claimant initiates an application for an original FDC
compensation claim online on January 1, 2013, (considered
the date of claim), but does not submit the completed
electronic application until September 1, 2013, the effective
date for any benefit awarded would be September 1, 2012, or
one year from the date VA received the fully developed
electronic claim.
• The one-year retroactive pay is always calculated from the
date the formal claim is filed.
26
Calculating the one-year retroactive date
• If evidence of record submitted with an FDC shows the level
of disability existed for one year prior to submission of the
claim, then the claim should be awarded with a one-year
retroactive effective date
• If there is medical evidence clearly showing that the claimed
medical condition did not exist, or had not manifested to a
compensable degree, either during the one year prior to the
date of claim, or following the date of claim, and evidence is
received supporting the disability while the claim is pending,
then the effective should be based on the specific facts in the
case.
Important: The one-year retroactive effective date cannot be
granted for claims removed from the FDC program
27
Time to Gather Evidence
• Lock in an effective date by paper or online
• A claimant can start a claim online at
https://www.ebenefits.va.gov, save the incomplete claim.
Then complete the submission of the claim and all the
supporting evidence once it is gathered
• A claimant has one year from the date the claim is initiated to
complete the submission of the fully developed claim to
preserve the initiation date for benefit payment
28
Forms and Information
Download any VA Form including EZ Forms at:
http://www.va.gov/vaforms/
DBQs can be downloaded at:
http://www.benefits.va.gov/COMPENSATION/dbq_ListByDBQFo
rmName.asp
FDC Website is located at:
http://www.benefits.va.gov/FDC/index.asp
eBenefits: www.eBenefits.va.gov
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eBenefits and SEP
Filing an electronic claim keeps the claim digital and allows
VSO’s to work in the Stakeholder Enterprise Portal (SEP).
– Enter/Update Dependency claims
– Accept/Decline new Power of Attorney requests
– Check the status of pending claims
– Upload supporting documents
– View payment history
– Complete some online claims forms; VA Form 21-526ez, VA Form
21-686C, VA Form 21-674, VA Form 21-4502, and VA Form 21-2680. VA Form
21-0781 and VA Form 21-8940 have been integrated into the 21-526EZ and
the questions that need to be answered for those forms will be brought up
through that process.
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Questions
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