One thing that drives me crazy is when VA doesn’t follow its own rules. A common example is a denial because the veteran used the wrong diagnostic label and VA failed to consider the condition reasonably described by the symptoms and evidence. A veteran does not have to diagnose himself or herself. Describe the symptoms and the benefit you are seeking clearly enough for VA to identify the claim. That defines the claim’s scope; the evidence still must establish entitlement to service connection.
One of the big things to understand is the scope of claim, which is not only the explicitly claimed conditions but also those reasonably implied by the evidence provided. This comprehensive guide outlines the key aspects of scope of claims and provides real-world case studies to illustrate how it works in practice.
What Does “Scope of Claim” Mean?
The “scope of claim” is not limited to the exact words or conditions a veteran lists in their application. Instead, it includes:
- Explicit Claims: Directly stated conditions, such as “left knee pain.”
- Reasonably raised issues: Conditions or theories reasonably encompassed by the claimant’s description, reported symptoms, and supporting evidence. Being within the scope means VA must address the matter; it does not mean the condition is automatically granted.
- Secondary complications: A condition caused or aggravated by a service-connected disability may be part of a pending claim when it is reasonably raised during VA’s processing of a properly initiated claim concerning the evaluation of the primary disability. Otherwise, VA may require a separate claim.
Legal Framework Supporting Scope of Claim
- Clemons v. Shinseki, 23 Vet. App. 1 (2009):
Veterans’ claims for mental health disorders must be construed broadly, encompassing all diagnoses supported by symptoms described. - DeLisio v. Shinseki, 25 Vet. App. 45 (2011):
VA must consider all issues raised by the evidence, even if the veteran didn’t explicitly claim them. - 38 C.F.R. § 3.310:
Governs secondary service connection, expanding a claim to include conditions caused or worsened by a service-connected disability.
Case Studies: Real-World Examples
Case Study 1: Expanding a Mental Health Claim
Scenario:
John, a Vietnam veteran, files a claim for Post-Traumatic Stress Disorder (PTSD) due to combat experiences. During his medical examination, the VA psychiatrist diagnoses him with major depressive disorder in addition to PTSD.
Outcome:
The VA expands the claim to include major depressive disorder as part of the broader mental health condition. This reflects the principles outlined in Clemons v. Shinseki, which ensure that veterans receive compensation for all conditions related to their described symptoms.
Key Takeaway:
Veterans don’t need to know their exact diagnosis—describing the symptoms is sufficient to invoke a claim’s broader scope.
Case Study 2: A Reasonably Raised Secondary Condition
Scenario:
Maria already has a service-connected knee disability and files a claim seeking a higher evaluation for it. During VA’s processing of that claim, she reports chronic back pain, and the medical evidence indicates that an altered gait from her knee disability may have caused or aggravated a back condition.
Outcome:
Because the evidence reasonably raises secondary service connection while VA is evaluating a properly initiated claim concerning the knee disability’s evaluation level, VA must consider, develop, and adjudicate the back condition as a possible complication under 38 C.F.R. § 3.155(d)(2). VA applies 38 C.F.R. § 3.310 to decide whether the evidence actually establishes that the knee disability caused or aggravated the back condition. The condition is not granted automatically.
Key Takeaway:
A claim concerning a primary disability does not automatically include every possible secondary condition. Under Bailey v. Wilkie, VA must address a secondary condition when it is reasonably raised during the processing of a properly initiated claim concerning the evaluation of the primary service-connected disability. When that connection is not reasonably raised in the pending claim, a separate formal claim may be required.
Case Study 3: Incorrect Denial Based on Narrow Interpretation of Claim
Scenario:
Jessica files a claim for foot pain, which she attributes to long marches during her service. The VA denies the claim, stating there is no diagnosis of a specific foot condition like plantar fasciitis. However, Jessica’s medical records mention stress fractures.
Outcome:
On appeal, the VA acknowledges the error and awards compensation for the stress fractures, as they were reasonably encompassed within the scope of Jessica’s original foot pain claim.
Key Takeaway:
Even if the VA denies a claim, veterans should appeal when they believe related conditions were overlooked.
Practical Advice for Veterans
- Detail Your Symptoms Thoroughly:
Use lay statements and medical evidence to describe all symptoms, even if you’re unsure of the diagnosis. File your claim broadly. On the claim form, if you have sinusitis, file for respiratory condition. If you have anxiety, file for mental health condition. That way, if the C&P exam diagnoses a different condition, they have to consider it. - File for Secondary Conditions:
If you suspect a condition is related to a service-connected disability, include it in your application or appeal. - Leverage VA Case Law:
Familiarize yourself with rulings like Clemons and DeLisio to understand your rights. - Work with Experts:
Seek help from VA-accredited representatives or attorneys to maximize the scope of your claim.
