### Section G. Benefits Under 38 U.S.C. 1151

#### Overview

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  33           General Information on Entitlement to Benefits 2-G-2
               Under 38 U.S.C. 1151                           

  34           Determining Entitlement to Benefits Under 38   2-G-8
               U.S.C. 1151                                    

  35           Preparing a Rating Decision Involving a Claim  2-G-11
               for Benefits Under 38 U.S.C. 1151              
  ------------ ---------------------------------------------- ------------

#### 33. General Information on Entitlement to Benefits Under 38 U.S.C. 1151

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains general information on            |
| troduction | > entitlement to benefits under 38 U.S.C. 1151,         |
|            | > including information on                              |
|            |                                                         |
|            | -   benefits under 38 U.S.C. 1151                       |
|            |                                                         |
|            | -   qualifying disability or death under 38 U.S.C. 1151 |
|            |                                                         |
|            | -   determining whether additional disability exists    |
|            |                                                         |
|            | -   establishing that VA fault was the proximate cause  |
|            |     of disability or death                              |
|            |                                                         |
|            | -   the definitions of ***express consent*** and        |
|            |     ***implied consent***                               |
|            |                                                         |
|            | -   establishing that an event was not reasonably       |
|            |     foreseeable                                         |
|            |                                                         |
|            | -   entitlement to compensation under 38 U.S.C. 1151    |
|            |     vs. service connection                              |
|            |                                                         |
|            | -   considering direct and presumptive service          |
|            |     connection                                          |
|            |                                                         |
|            | -   obtaining independent medical evidence and medical  |
|            |     opinions, and                                       |
|            |                                                         |
|            | -   additional disability or death resulting from       |
|            |     treatment or care in a non-VA facility under VA     |
|            |     contract.                                           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

Continued on next page

33\. General Information on Entitlement to Benefits Under 38 U.S.C.
1151, Continued

+------------+---------------------------------------------------------+
| ##### a.   | > [38 U.S.C.                                            |
| Benefits U | > 1151](http://assembler.law.cornell.edu                |
| nder 38 U. | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| S.C. 1151  | > provides for the payment of compensation for          |
|            | > additional disability or death that is                |
|            |                                                         |
|            | -   not the result of the veteran's willful misconduct, |
|            |     and                                                 |
|            |                                                         |
|            | -   attributable to                                     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   hospital care, medical or surgical treatment, or    |
|            |     examination furnished the veteran under any law     |
|            |     administered by the Secretary, either by a VA       |
|            |     employee or in a VA facility as defined in [38      |
|            |     U.S.C.                                              |
|            |     1701(3)(A)](http://assembler.law.cornell.edu        |
|            | /uscode/html/uscode38/usc_sec_38_00001701----000-.html) |
|            |                                                         |
|            | -   participation in vocational rehabilitation training |
|            |     under [38 U.S.C. Chapter                            |
|            |     31](http://straylight.law.cornell.edu               |
|            | /uscode/html/uscode38/usc_sup_01_38_10_III_20_31.html), |
|            |     or                                                  |
|            |                                                         |
|            | -   participation in compensated work therapy (CWT).    |
|            |                                                         |
|            | > Award benefits for qualifying additional disability   |
|            | > or death under [38 U.S.C.                             |
|            | > 1151](http://assembler.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
|            | > in the same manner as if the disability or death were |
|            | > service-connected (SC).                               |
|            | >                                                       |
|            | > ***Note***: Per [*VAOPGCPREC                          |
|            | > 8-97*](http://www1.va.gov/ogc/docs/Prc08-97.doc),     |
|            | > compensation may be paid for disability that is       |
|            | > secondary to disability for which compensation is     |
|            | > payable under [38 U.S.C.                              |
|            | > 1151](http://assembler.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html). |
|            | >                                                       |
|            | > ***Reference***: For more information on entitlement  |
|            | > to compensation or DIC under the provisions of [38    |
|            | > U.S.C.                                                |
|            | > 1151](http://assembler.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html), |
|            | > see [38 CFR                                           |
|            | > 3.361](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_361.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

33\. General Information on Entitlement to Benefits Under 38 U.S.C.
1151, Continued

+------------+---------------------------------------------------------+
| ##### b. Q | > In order to meet the qualifications of [38 U.S.C.     |
| ualifying  | > 1151](http://straylight.law.cornell.edu/              |
| Disability | uscode/html/uscode38/usc_sec_38_00001151----000-.html), |
|  or Death  | > the proximate cause of additional disability or death |
| Under 38 U | > must be                                               |
| .S.C. 1151 |                                                         |
|            | -   carelessness, negligence, lack of proper skill,     |
|            |     error in judgment, or similar instance of fault on  |
|            |     the part of VA in furnishing the hospital care,     |
|            |     medical or surgical treatment, or examination       |
|            |                                                         |
|            | -   an event not reasonably foreseeable, or             |
|            |                                                         |
|            | -   the provision of                                    |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   training and rehabilitation by VA or one of its     |
|            |     service providers as part of an approved            |
|            |     rehabilitation program under [38 U.S.C. Chapter     |
|            |     31](http://straylight.law.cornell.edu               |
|            | /uscode/html/uscode38/usc_sup_01_38_10_III_20_31.html), |
|            |     or                                                  |
|            |                                                         |
|            | -   a CWT program.                                      |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The eligibility requirement that fault on the part  |
|            |     of the VA be found, or that death or disability be  |
|            |     the result of an unforeseeable event, applies only  |
|            |     to claims received on or after October 1, 1997.     |
|            |                                                         |
|            | -   Eligibility based on participation in a CWT program |
|            |     is restricted to claims that were pending or        |
|            |     received on or after November 1, 2000.              |
|            |                                                         |
|            | -   Evidence showing that a veteran received VA medical |
|            |     care, treatment, or examination, and that the       |
|            |     veteran has an additional disability or died, does  |
|            |     not establish proximate cause.                      |
|            |                                                         |
|            | > ***Reference***: For more information on proximate    |
|            | > cause, see [38 CFR                                    |
|            | > 3.361(d)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_361.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c    | > To determine whether a veteran has incurred           |
| . Determin | > additional disability under [38 U.S.C.                |
| ing Whethe | > 1151](http://straylight.law.cornell.edu/              |
| r Addition | uscode/html/uscode38/usc_sec_38_00001151----000-.html), |
| al Disabil | > compare the veteran's condition immediately before    |
| ity Exists | > the beginning of the VA medical care, training, or    |
|            | > CWT program on which the claim is based to his/her    |
|            | > condition afterwards.                                 |
|            | >                                                       |
|            | > ***Note***: Each body part should be compared         |
|            | > separately.                                           |
|            | >                                                       |
|            | > ***Reference***: For more information on determining  |
|            | > whether a veteran has incurred additional disability, |
|            | > see [38 CFR                                           |
|            | > 3.361(b)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_361.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

33\. General Information on Entitlement to Benefits Under 38 U.S.C.
1151, Continued

+------------+---------------------------------------------------------+
| #####      | > To establish that fault on the part of VA in          |
|  d. Establ | > furnishing medical care, treatment or examination was |
| ishing Fau | > the proximate cause of a veteran's disability or      |
| lt on the  | > death, the evidence must show that                    |
| Part of VA |                                                         |
|            | -   the medical care, treatment, or examination caused  |
|            |     the additional disability or death, *and*           |
|            |                                                         |
|            | -   VA                                                  |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   failed to exercise the degree of care that would    |
|            |     have been expected of a reasonable health-care      |
|            |     provider, or                                        |
|            |                                                         |
|            | -   furnished the care without the veteran's or         |
|            |     veteran's representative's informed consent.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### e    | > ***Express consent*** is consent that has been        |
| . Definiti | > clearly stated either orally or in writing.           |
| ons: Expre | >                                                       |
| ss Consent | > ***Implied consent*** is consent that may be inferred |
|  and Impli | > from the circumstances in the case. ***Example***: If |
| ed Consent | > a veteran requires emergency care to preserve life or |
|            | > prevent serious impairment to health, and the veteran |
|            | > or his/her representative is unable to consent orally |
|            | > or in writing, then consent is implied.               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > An event is considered "not reasonably foreseeable"   |
| f. Establi | > if it is not the type of risk that would be disclosed |
| shing That | > as part of the informed consent procedures shown in   |
|  an Event  | > [38 CFR                                               |
| Was Not Re | > 17.32](http://ww                                      |
| asonably F | w.warms.vba.va.gov/regs/38CFR/BOOKI/PART17/s17_32.DOC). |
| oreseeable | >                                                       |
|            | > The incident need not be completely unimaginable, but |
|            | > it must be one that a reasonable health-care provider |
|            | > would not consider an ordinary risk of the treatment  |
|            | > provided.                                             |
+------------+---------------------------------------------------------+

Continued on next page

33\. General Information on Entitlement to Benefits Under 38 U.S.C.
1151, Continued

+------------+---------------------------------------------------------+
| ##### g. E | > Although compensation or DIC is payable under [38     |
| ntitlement | > U.S.C.                                                |
|  to Compen | > 1151](http://straylight.law.cornell.edu               |
| sation Und | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| er 38 U.S. | > as if the additional disability or death were SC, the |
| C. 1151 vs | > additional disability or death is *not* actually SC.  |
| . Service  |                                                         |
| Connection |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Do not put direct service connection at issue if the  |
| ### h. Con | > only issue raised is compensation under [38 U.S.C.    |
| sidering D | > 1151](http://straylight.law.cornell.edu/              |
| irect and  | uscode/html/uscode38/usc_sec_38_00001151----000-.html), |
| Presumptiv | > and the disability is clearly one that arose many     |
| e Service  | > years after service or coincident with treatment.     |
| Connection | >                                                       |
|            | > ***Note***: Undertake development and consider        |
|            | > awarding service connection on a presumptive basis if |
|            | > the disability in question arose within the           |
|            | > applicable presumptive period following release from  |
|            | > active duty.                                          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### i.   | > To clarify whether the care, treatment, or            |
|  Obtaining | > examination at issue resulted in additional           |
|  Independe | > disability or death, it may be necessary to obtain    |
| nt Medical |                                                         |
|  Evidence  | -   a medical opinion from a VA medical facility as     |
| and Medica |     shown in [M21-1MR, Part III, Subpart iv,            |
| l Opinions |     3.A.9](../pt03_sp04_ch03_secA.xml#III.iv.3.A.9)     |
|            |                                                         |
|            | -   independent medical evidence, such as               |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   a medical statement provided by a regional office   |
|            |     (RO) rating specialist who is a qualified medical   |
|            |     professional, such as a physician, physician's      |
|            |     assistant, or registered nurse, and not a signatory |
|            |     to the rating, or                                   |
|            |                                                         |
|            | -   information from a medical treatise, such as *The   |
|            |     Merck Manual of Diagnosis and Therapy, Cecil        |
|            |     Textbook of Medicine,* or *Physician's Desk         |
|            |     Reference (PDR)*, and/or                            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   an independent medical opinion under [38 CFR        |
|            |     3.328](http://w                                     |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_328.DOC), |
|            |     but only when warranted by the medical complexity   |
|            |     or controversy involved in the case.                |
|            |                                                         |
|            | > ***Reference***: For more information on obtaining    |
|            | > independent medical opinions under [38 CFR            |
|            | > 3.328](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_328.DOC), |
|            | > see [M21-1MR, Part III, Subpart iv, 3.A.9.f through   |
|            | > i](../pt03_sp04_ch03_secA.xml#III.iv.3.A.f).          |
+------------+---------------------------------------------------------+

Continued on next page

33\. General Information on Entitlement to Benefits Under 38 U.S.C.
1151, Continued

+------------+---------------------------------------------------------+
| ##### j. D | > Hospital care, for the purposes of establishing       |
| isability  | > entitlement to compensation under [38 U.S.C.          |
| or Death R | > 1151](http://assembler.law.cornell.edu/               |
| esulting F | uscode/html/uscode38/usc_sec_38_00001151----000-.html), |
| rom Treatm | > does not include treatment or care provided in a      |
| ent or Car | > non-VA facility under VA contract.                    |
| e in a Non | >                                                       |
| -VA Facili | > VA treatment or examination resulting in additional   |
| ty Under V | > disability or death coincident with a veteran's       |
| A Contract | > residence in a contracted non-VA facility *might*     |
|            | > result in eligibility under [38 U.S.C.                |
|            | > 1151](http://assembler.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html). |
|            | >                                                       |
|            | > ***Reference***: For more information, see [38 CFR    |
|            | > 3.361(f)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_361.DOC). |
+------------+---------------------------------------------------------+

#### 34. Determining Entitlement to Benefits Under 38 U.S.C. 1151

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on considering        |
| troduction | > entitlement to benefits under 38 U.S.C. 1151,         |
|            | > including information on                              |
|            |                                                         |
|            | -   disability resulting from                           |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   an examination                                      |
|            |                                                         |
|            | -   an act of omission                                  |
|            |                                                         |
|            | -   a premature discharge                               |
|            |                                                         |
|            | -   medication, and/or                                  |
|            |                                                         |
|            | -   vocational rehabilitation training or a CWT         |
|            |     program, and                                        |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   disability resulting from veteran's failure to      |
|            |     follow medical instructions.                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > [38 U.S.C.                                            |
|  Consideri | > 1151](http://straylight.law.cornell.edu               |
| ng Compens | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| ation for  | > authorizes compensation for disability resulting from |
| Disability | > a veteran's "having submitted to an examination"      |
|  Resulting | > under any law administered by VA.                     |
|  From an E | >                                                       |
| xamination | > ***Note***: The U.S. Court of Appeals for Veterans    |
|            | > Claims (CAVC) has interpreted this portion of the     |
|            | > statute to mean that compensation is payable *only*   |
|            | > for injuries that result from the examination itself, |
|            | > not from the process of reporting for the             |
|            | > examination.                                          |
|            | >                                                       |
|            | > ***Example***: A veteran injured by another patient   |
|            | > while awaiting the start of his/her scheduled VA      |
|            | > examination would not qualify for compensation for    |
|            | > residuals of that injury under [38 U.S.C.             |
|            | > 1151](http://assembler.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html). |
|            | >                                                       |
|            | > ***Reference***: For more information on compensation |
|            | > for a disability resulting from VA examination, see   |
|            | > [*Sweitzer v.                                         |
|            | > Brown*](                                              |
|            | http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bms), |
|            | > 5 Vet. App. 503 (1993).                               |
+------------+---------------------------------------------------------+

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34\. Determining Entitlement to Benefits Under 38 U.S.C. 1151, Continued

+------------+---------------------------------------------------------+
| ##         | > Entitlement to compensation under [38 U.S.C.          |
| ### b. Con | > 1151](http://assembler.law.cornell.edu                |
| sidering C | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| ompensatio | > may be based on acts of omission as well as acts of   |
| n for Disa | > commission.                                           |
| bility Res | >                                                       |
| ulting Fro | > A veteran may be entitled to benefits under [38       |
| m an Act o | > U.S.C.                                                |
| f Omission | > 1151](http://assembler.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
|            | > if VA failed to perform one of the following actions: |
|            |                                                         |
|            | -   timely diagnose or properly treat a disability,     |
|            |     thereby causing increased disability or death,      |
|            |     and/or                                              |
|            |                                                         |
|            | -   obtain informed consent from the veteran or the     |
|            |     veteran's representative prior to treatment.        |
|            |                                                         |
|            | > ***Note***: The natural progression, that is,         |
|            | > worsening, of a disease or injury may be the basis of |
|            | > eligibility under [38 U.S.C.                          |
|            | > 1151](http://assembler.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
|            | > only if it is attributable to VA's failure to timely  |
|            | > diagnose or properly treat the disease or injury.     |
|            | >                                                       |
|            | > ***References***: For more information on             |
|            |                                                         |
|            | -   informed consent, see [38 CFR                       |
|            |     17.34](http://ww                                    |
|            | w.warms.vba.va.gov/regs/38CFR/BOOKI/PART17/S17_34.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   the natural progression of a disease or injury, see |
|            |     [38 CFR                                             |
|            |     3.361(c)(2)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_361.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Compensation may be payable under [38 U.S.C.          |
| ## c. Cons | > 1151](http://assembler.law.cornell.edu                |
| idering Co | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| mpensation | > when a physician determines that a patient should be  |
|  for Disab | > discharged from a hospital after a period of          |
| ility Resu | > treatment, but the patient claims that the discharge  |
| lting From |                                                         |
|  Premature | -   was too early, and                                  |
|  Discharge |                                                         |
|            | -   lead to a relapse and worsening of the disability.  |
|            |                                                         |
|            | > Consider whether the timing of the discharge          |
|            | > aggravated the disability beyond the level of natural |
|            | > progression (that is, worsening).                     |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Development should include a request for a medical  |
|            |     certificate indicating that the                     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   veteran's condition at discharge was not stable,    |
|            |     and                                                 |
|            |                                                         |
|            | -   discharge was premature.                            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   A medical opinion may be necessary in such a case.  |
+------------+---------------------------------------------------------+

Continued on next page

34\. Determining Entitlement to Benefits Under 38 U.S.C. 1151, Continued

+------------+---------------------------------------------------------+
| ####       | > Compensation is payable under [38 U.S.C.              |
| # d. Consi | > 1151](http://straylight.law.cornell.edu               |
| dering Com | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| pensation  | > for any disability caused by medication that was      |
| for Disabi | > prescribed by VA and taken or administered as         |
| lity Resul | > prescribed, if the disability was directly due to     |
| ting From  |                                                         |
| Medication | -   fault on the part of the VA, or                     |
|            |                                                         |
|            | -   an incident that could not have been reasonably     |
|            |     foreseen.                                           |
|            |                                                         |
|            | > ***Example***: Compensation is payable under [38      |
|            | > U.S.C.                                                |
|            | > 1151](http://assembler.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
|            | > if                                                    |
|            |                                                         |
|            | -   VA prescribed a medication at ten times the proper  |
|            |     dosage, *and*                                       |
|            |                                                         |
|            | -   additional permanent disability or death resulted   |
|            |     from the erroneous prescription.                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Compensation may be payable under [38 U.S.C.          |
| e. Conside | > 1151](http://straylight.law.cornell.edu               |
| ring Compe | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| nsation fo | > for disability resulting from the veteran's           |
| r Disabili | > participation in an essential activity or function of |
| ty Resulti | > vocational rehabilitation training or a CWT program.  |
| ng From Vo | >                                                       |
| cational R | > It need not be shown that VA approved the specific    |
| ehabilitat | > activity that resulted in disability, as long as the  |
| ion Traini | > activity is considered a necessary component of the   |
| ng or a CW | > training or work therapy VA authorized.               |
| T Program  | >                                                       |
|            | > ***Reference***: For more information, see [38 CFR    |
|            | > 3.361(d)(3)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_361.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > In some cases, the evidence will show that, following |
| f. Disabil | > VA treatment or surgery, the veteran                  |
| ity Result |                                                         |
| ing From V | -   failed to follow post-treatment medical             |
| eteran's F |     instructions, and                                   |
| ailure to  |                                                         |
| Follow Ins | -   incurred or aggravated a disability that would not  |
| tructions  |     have developed had he/she followed instructions.    |
|            |                                                         |
|            | > In such cases, this failure may constitute an         |
|            | > intercurrent cause, thereby *precluding* payment of   |
|            | > benefits under [38 U.S.C.                             |
|            | > 1151](http://assembler.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html). |
+------------+---------------------------------------------------------+

#### 35. Preparing a Rating Decision Involving a Claim for Benefits Under 38 U.S.C. 1151

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on preparing a rating |
| troduction | > decision involving a claim for benefits under 38      |
|            | > U.S.C.1151, including information on                  |
|            |                                                         |
|            | -   determining entitlement to benefits for an          |
|            |     additional disability                               |
|            |                                                         |
|            | -   determining the additional degree of disability     |
|            |                                                         |
|            | -   preparing the *Reasons for Decision*                |
|            |                                                         |
|            | -   making uncorroborated conclusions in the rating     |
|            |     decision                                            |
|            |                                                         |
|            | -   combining the disability ratings of qualifying      |
|            |     disabilities under 38 U.S.C. 1151 and SC            |
|            |     disabilities                                        |
|            |                                                         |
|            | -   possible eligibility for ancillary benefits         |
|            |                                                         |
|            | -   ancillary benefits not available by reason of a     |
|            |     qualifying disability under 38 U.S.C. 1151, and     |
|            |                                                         |
|            | -   obtaining an advisory opinion.                      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a. D | > Establish entitlement to benefits for an additional   |
| etermining | > disability under [38 U.S.C.                           |
|  Entitleme | > 1151](http://straylight.law.cornell.edu/              |
| nt to Bene | uscode/html/uscode38/usc_sec_38_00001151----000-.html), |
| fits for A | > if the evidence shows aggravation of a                |
| dditional  | > nonservice-connected (NSC), pre-existing condition as |
| Disability | > a result of                                           |
|            |                                                         |
|            | -   VA medical treatment or examination                 |
|            |                                                         |
|            | -   a course of vocational rehabilitation, or           |
|            |                                                         |
|            | -   a CWT program.                                      |
+------------+---------------------------------------------------------+

Continued on next page

35\. Preparing a Rating Decision Involving a Claim for Benefits Under 38
U.S.C. 1151, Continued

+------------+---------------------------------------------------------+
| #####      | > Follow the steps in the table below to determine the  |
| b. Determi | > additional degree of disability for which benefits    |
| ning the A | > are payable under [38 U.S.C.                          |
| dditional  | > 1151](http://assembler.law.cornell.edu/               |
| Degree of  | uscode/html/uscode38/usc_sec_38_00001151----000-.html). |
| Disability |                                                         |
+------------+---------------------------------------------------------+

+-------+--------------------------------------------------------------+
| Step  | Action                                                       |
+-------+--------------------------------------------------------------+
| 1     | Determine the current level of disability (expressed as a    |
|       | percentage) based on all the symptoms and findings.          |
+-------+--------------------------------------------------------------+
| 2     | Determine the level of disability prior to the treatment or  |
|       | examination, vocational rehabilitation, or participation in  |
|       | CWT that resulted in additional disability.                  |
+-------+--------------------------------------------------------------+
| 3     | Subtract the percentage of disability reached in step 2 from |
|       | the percentage of disability reached in step 1.              |
|       |                                                              |
|       | ***Notes***:                                                 |
|       |                                                              |
|       | -   If the percentage of disability in step 1 is 100 , do    |
|       |     not subtract the percentage of disability in step 2,     |
|       |     even if it is also 100.                                  |
|       |                                                              |
|       | -   If a percentage of disability cannot be determined in    |
|       |     step 2, no subtraction may be made.                      |
+-------+--------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Reference***: For more information on rating a disability for    |
| > which compensation is payable under [38 U.S.C.                      |
| > 1151](http://straylight.l                                           |
| aw.cornell.edu/uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| > as if it were SC, see [*VAOPGCPREC                                  |
| > 4-2001*](http://www.va.gov/ogc/docs/prc04-2001.doc).                |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Provide an adequate discussion of the factual bases   |
| # c. Prepa | > for the claim in the *Reasons for Decision* section   |
| ring the R | > of the rating decision. Indicate whatever surgery,    |
| easons for | > treatment, or therapy was provided.                   |
|  Decision  | >                                                       |
|            | > If VA treatment is found to have been erroneous,      |
|            | > resulting in an additional disability, discuss such   |
|            | > fault as the basis of an award of benefits under [38  |
|            | > U.S.C.                                                |
|            | > 1151](http://straylight.law.cornell.edu/              |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html). |
+------------+---------------------------------------------------------+

Continued on next page

35\. Preparing a Rating Decision Involving a Claim for Benefits Under 38
U.S.C. 1151, Continued

+------------+---------------------------------------------------------+
| #####      | > Do not make uncorroborated conclusions in the rating  |
|  d. Making | > decision that a relationship between the treatment,   |
|  Uncorrobo | > surgery, or medication provided and the claimed       |
| rated Conc | > disability does not exist.                            |
| lusions in | >                                                       |
|  the Ratin | > ***Example***: Without corroborating medical          |
| g Decision | > evidence, a Rating Veterans Service Representative    |
|            | > (RVSR) may not simply state that                      |
|            |                                                         |
|            | -   the evidence does not show a myelogram caused a     |
|            |     claimant's tinnitus, or                             |
|            |                                                         |
|            | -   it is unlikely that the veteran's medications       |
|            |     caused a claimed side effect.                       |
|            |                                                         |
|            | > ***Reference***: For information on evaluating        |
|            | > medical evidence for a rating decision, see [M21-1MR, |
|            | > Part III, Subpart iv,                                 |
|            | > 5.5](../pt03_sp04_ch05.xml#III.iv.5.5).               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### e.   | > Combine the disability rating(s) assigned to          |
| Combining  | > disabilities for which compensation is payable under  |
| the Disabi | > [38 U.S.C.                                            |
| lity Ratin | > 1151](http://assembler.law.cornell.edu                |
| gs of Qual | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| ifying Dis | > with the disability ratings assigned to SC            |
| abilities  | > disabilities, as if the former were                   |
| Under 38 U | > service-connected.                                    |
| .S.C. 1151 | >                                                       |
|  and SC Di | > If two or more disabilities (at least one being a     |
| sabilities | > qualifying disability under [38 U.S.C.                |
|            | > 1151](http://assembler.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001151----000-.html)) |
|            | > are rated 0 percent disabling but interfere with the  |
|            | > veteran's employability, the assignment of a 10       |
|            | > percent disability rating under [38 CFR               |
|            | > 3.324](http://                                        |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_323.DOC) |
|            | > is acceptable.                                        |
|            | >                                                       |
|            | > ***Note***: [38 U.S.C.                                |
|            | > 1151](http://assembler.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
|            | > disabilities may serve as the basis of an individual  |
|            | > unemployability (IU) award.                           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > A veteran with a qualifying disability under [38      |
| ### f. Pos | > U.S.C.                                                |
| sible Elig | > 1151](http://assembler.law.cornell.edu                |
| ibility fo | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
| r Ancillar | > may also be eligible for                              |
| y Benefits |                                                         |
|            | -   a clothing allowance                                |
|            |                                                         |
|            | -   specially adapted housing benefits, including a     |
|            |     special housing adaptation grant, and               |
|            |                                                         |
|            | -   an automobile or adaptive equipment benefits.       |
|            |                                                         |
|            | > ***Reference***: For more information on ancillary    |
|            | > benefits, see                                         |
|            |                                                         |
|            | -   [M21-1MR, Part IX, Subpart                          |
|            |     i](http://                                          |
|            | vbaw.vba.va.gov/bl/21/M21-1MR/m21-1mr_main.htm#pt9_spi) |
|            |                                                         |
|            | -   [M21-1MR, Part III, Subpart iv,                     |
|            |     6.B.3](../pt03_sp04_ch06_secB.xml#III.iv.6.B.3),    |
|            |     and                                                 |
|            |                                                         |
|            | -   [M21-1MR, Part IV, Subpart iii,                     |
|            |                                                         |
|            |  3.G.39.d](../pt04_sp03_ch03_secG.xml#IV.iii.3.G.39.d). |
+------------+---------------------------------------------------------+

Continued on next page

35\. Preparing a Rating Decision Involving a Claim for Benefits Under 38
U.S.C. 1151, Continued

+------------+---------------------------------------------------------+
| ##### g.   | > The following ancillary benefits are not available by |
| Ancillary  | > reason of a qualifying disability under [38 U.S.C.    |
| Benefits N | > 1151](http://straylight.law.cornell.edu/              |
| ot Availab | uscode/html/uscode38/usc_sec_38_00001151----000-.html): |
| le by Reas |                                                         |
| on of a Qu | -   Service Disabled Veteran (RH) Insurance             |
| alifying D |                                                         |
| isability  | -   the Civilian Health and Medical Program of VA       |
| Under 38 U |     (CHAMPVA)                                           |
| .S.C. 1151 |                                                         |
|            | -   waiver of the loan guaranty funding fee             |
|            |                                                         |
|            | -   [38 U.S.C. Chapter                                  |
|            |     31](http://straylight.law.cornell.ed                |
|            | u/uscode/html/uscode38/usc_sup_01_38_10_III_20_31.html) |
|            |     education benefits                                  |
|            |                                                         |
|            | -   [38 U.S.C. Chapter                                  |
|            |     35](http://straylight.law.cornell.ed                |
|            | u/uscode/html/uscode38/usc_sup_01_38_10_III_20_35.html) |
|            |     education benefits                                  |
|            |                                                         |
|            | -   the 10-point Civil Service Preference               |
|            |                                                         |
|            | -   the special allowances under [38 U.S.C.             |
|            |     1312(a)](http://straylight.law.cornell.edu          |
|            | /uscode/html/uscode38/usc_sec_38_00001312----000-.html) |
|            |     and *Public Law (PL) 87-377*, Section 156, Restored |
|            |     Entitlement Program for Survivors (REPS)            |
|            |                                                         |
|            | -   SC burial allowance, and                            |
|            |                                                         |
|            | -   loan guaranty benefits for a surviving spouse.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### h.   | > Submit unusually difficult cases involving claims for |
|  Obtaining | > compensation under [38 U.S.C.                         |
|  an Adviso | > 1151](http://assembler.law.cornell.edu                |
| ry Opinion | /uscode/html/uscode38/usc_sec_38_00001151----000-.html) |
|            | > to VA Central Office (CO) (211B) for an advisory      |
|            | > opinion.                                              |
|            | >                                                       |
|            | > ***Reference***: For more information on CO guidance  |
|            | > and advisory opinions, see [M21-1MR, Part III,        |
|            | > Subpart vi,                                           |
|            | > 1](http://vbaw.v                                      |
|            | ba.va.gov/bl/21/M21-1MR/m21-1mr_main.htm#pt3_spvi_ch1). |
+------------+---------------------------------------------------------+