United States General Accounting Office

GAO Report to the Ranking Minority Member,

Committee on Veterans’ Affairs, U.S.

Senate

May 1996 VETERANS’

COMPENSATION

Evidence Considered

in Persian Gulf War

Undiagnosed Illness

Claims

G O A

years

1921 - 1996

GAO/HEHS-96-112

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-265991 

May 28, 1996

The Honorable John D. Rockefeller IV

Ranking Minority Member

Committee on Veterans’ Affairs

United States Senate

Dear Senator Rockefeller:

Over 700,000 men and women served in Southwest Asia during the Persian

Gulf War. Some of these veterans began experiencing symptoms—such as

fatigue, weight loss, and skin conditions—that could not be diagnosed or

associated with a specific illness or disease. In 1994, the Congress enacted

legislation allowing the Department of Veterans Affairs (VA) to pay

compensation benefits to veterans for Persian Gulf related disabilities

caused by undiagnosed illnesses. As of July 1995, VA had denied almost

95 percent of the 4,144 claims it had processed for Persian Gulf veterans

claiming such disabilities.

Concerned about the high denial rate, you asked us to identify the

procedures that VA used to process Persian Gulf War undiagnosed illness

claims. In this report, we identify (1) the evidence standards that VA has

established to process Persian Gulf claims, (2) the evidence in the claim

files that VA considered in reaching its decisions, and (3) VA’s reporting of

the reasons for denial.

To accomplish our objectives we conducted discussions with officials of

VA’s central office and its four area processing offices that process Persian

Gulf claims and we obtained and analyzed pertinent documents and

records, such as VA’s regulation and procedures for processing Persian

Gulf claims. We also analyzed a nationally representative sample of the

undiagnosed illness claims that VA had denied as of September 1995 and

for purposes of comparison, we reviewed a random, nonstatistical sample

of granted claims. Further details of our scope and methodology are in

appendix I.

Results in Brief Before compensation can be paid for an undiagnosed illness, VA requires

evidence that a chronic disability developed within 2 years of a veteran’s

service in the Persian Gulf War. Such evidence could include support from

an examining physician and nonmedical evidence that can be

Page 1 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

independently verified, such as lost time at work or statements from

individuals familiar with the veteran’s condition.

For the denied undiagnosed illness claims that we reviewed, the evidence

included mainly service medical records and VA medical exams. Few of the

files contained nonmedical evidence. For the granted claims, the evidence

was similar but, in general, showed a history of treatment for the claimed

condition. For the most part, VA denied the claims for a lack of evidence.

Both VA and the veterans may have contributed to this lack of evidence. In

some instances, VA did not provide required assistance or clear and useful

information to veterans regarding the type of evidence needed to support

undiagnosed illness claims. On the other hand, even when VA followed

appropriate procedures to develop the claims, veterans did not always

provide the evidence needed to support their claims. Although VA has

rarely granted compensation for undiagnosed illnesses, many Gulf War

veterans have received VA benefits for diagnosable service-connected

conditions that accompanied their undiagnosed illness claims. Of the

denied claims that we reviewed, 60 percent of the veterans had been

granted compensation for diagnosable illnesses.

VA’s reports to the Congress regarding undiagnosed illness claims have not

always accurately described the reasons that claims were denied. In most

of the denied cases that we reviewed, VA found insufficient evidence to

support the claimed disability but reported that the claims were denied

because the disability did not arise during the 2-year presumptive period.

These VA reports suggest that veterans had well-documented disabling

conditions but would receive no compensation simply because their

disability arose at some time outside of the presumptive period. Our work

suggests that in most cases, even with an extended presumptive period,

more evidence would have been needed before VA could grant

compensation. VA plans to assess the extent of the problem and take the

necessary corrective action.

Background As has been reported by many researchers, some Gulf War veterans

developed illnesses that could not be diagnosed or defined and for which

other causes could not be specifically identified. These illnesses have been

attributed to many sources, including a large number of unusual

environmental hazards found in the Gulf. The Congress enacted the

Persian Gulf War Veterans’ Benefits Act1

 (P.L. 103-446, Nov. 2,

1994) which, among other things, allowed VA to pay disability

1

Title I of the Veterans’ Benefits Improvements Act of 1994.

Page 2 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

compensation to veterans suffering from undiagnosed illnesses attributed

to their service in the Persian Gulf. Compensable conditions include but

are not limited to abnormal weight loss, cardiovascular symptoms, fatigue,

gastrointestinal symptoms, headaches, joint and muscle pains, menstrual

disorders, neurologic symptoms, neuropsychological symptoms, skin

disorders, respiratory disorders, and sleep disturbances.

Under the procedures that VA established to process undiagnosed illness

claims, veterans submit completed claim forms to a VA regional office

(VARO). Each VARO is responsible for fully developing the claims. VAROs

obtain medical records from the military services; arrange for a VA medical

examination; and obtain evidence from other sources, such as private

health care providers or knowledgeable lay persons, if the veteran

identifies such sources. Once the claim is developed, the claims file is

transferred to one of the four area processing offices that VA has

designated for processing undiagnosed illness claims.

As mentioned earlier, over 700,000 men and women served in the Persian

Gulf War. VA reported that as of February 1996, it has processed 7,845

undiagnosed illness claims and has identified an additional 6,655 claims

that are being evaluated for undiagnosed illnesses.2

 Of the processed

claims, VA had denied compensation for undiagnosed illness to 7,424

veterans—a denial rate of 95 percent.

VA Procedures

Require Veterans to

Provide Evidence

Proving Their Claims

In February 1995, VA issued a regulation (38 C.F.R. 3.317) that specifies the

evidence required before compensation can be paid for an undiagnosed

illness claim. Under the regulation, veterans must provide objective

indications of a chronic disability. Objective indications include both

signs—evidence perceptible to the examining physician—and other

nonmedical indications that are capable of independent verification. In the

final rule, VA explained that nonmedical indicators of a disabling illness

include but are not limited to such circumstances or events as (1) time lost

from work; (2) evidence that a veteran has sought medical treatment for

his or her symptoms; and (3) evidence affirming changes in the veteran’s

appearance, physical abilities, or mental or emotional attitude. The

evidence requirements contained in the regulation are consistent with the

Joint Explanatory Statement that accompanied the Veterans’ Benefits

Improvements Act of 1994.

2

VA reviews all Persian Gulf compensation claims that are based on exposure to environmental

hazards to determine if benefits could be granted for undiagnosed illness whether or not the veteran

claims such an illness.

Page 3 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

According to the VA regulation, a veteran can only be compensated for

disabilities caused by undiagnosed illnesses that (1) manifest themselves

during service in the Gulf War or (2) arise within 2 years of a veteran’s

departure from the Persian Gulf. If the illness arose after the veteran left

the Gulf, the veteran must be at least 10-percent disabled to be

compensated. In addition, the veteran must demonstrate that the disabling

condition is chronic—present for 6 months or longer.

In some cases, lay statements can provide critical support for a veteran’s

undiagnosed illness claim. As stated in the VA claims processing manual,

lay statements may be especially important in cases where an undiagnosed

illness is manifest solely by symptoms that the veteran reports and that

would, therefore, not be subject to verification through medical

examination. Examples of such symptoms include headaches and fatigue.

According to VA, lay statements from individuals who establish that they

are able from personal experience to make their observations or

statements will be considered as evidence if they support the conclusion

that a disability exists.

While veterans are ultimately responsible for proving their claims, VA is

required by statute to assist the veteran in developing facts to prove the

claim. The U.S. Court of Veterans’ Appeals has also held in its decisions

that VA has a duty to assist veterans with proving their claims and is

required to obtain relevant facts from sources identified by claimants. A VA

letter dated February 15, 1995, instructed all VA regional offices that “if a

veteran alleges that a disability began after military service, request

objective evidence (lay or medical) to establish that fact.”

Experience in

Reviewing Claims

Evidence

Many types of evidence can be used to support undiagnosed illness claims.

The denied claims that we reviewed contained primarily service medical

records and VA medical examinations. About 15 percent of the claims

included medical records from private physicians seen by the veterans

after leaving military service and less than 3 percent contained nonmedical

evidence related to an undiagnosed illness, such as lay statements and

records showing lost time from work.

The granted claims that we reviewed also contained primarily service

medical records and VA examinations. In these cases, however, veterans

were usually able to provide VA with a history, after leaving the Persian

Gulf, of treatment for the granted undiagnosed condition. Some granted

Page 4 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

claims were supported with nonmedical evidence, such as a sworn

statement from an individual with knowledge of the veteran’s disability.3

Many of the veterans evaluated for undiagnosed illnesses are also

examined for other diagnosable service-connected illnesses and injuries.

While VA does not often grant compensation for undiagnosed conditions,

these veterans often receive compensation for diagnosable injuries or

illnesses. Of the cases that we reviewed where the claimed undiagnosed

illness(es) had been denied, about 60 percent of the veterans had been

granted compensation for at least one service-connected diagnosable

condition, such as hypertension, hearing loss, or knee disorders. About

one-half of these veterans were granted a disability payment; the

remainder, with minor impairments, are eligible for free care for their

conditions through the VA medical system.

VA Did Not Always Provide

Required Assistance or

Clear and Useful

Information

The lack of evidence to support undiagnosed illness claims may in part be

the result of poor VA procedures to elicit such information, as the following

examples indicate.

• In late 1995, VA’s central office conducted a review of 203 completed

undiagnosed illness claims. VA found that additional specialty

examinations should have been ordered in 23 cases (about 11 percent). At

the time of our work, VA stated that the required examinations would be

scheduled and the veterans’ cases would be reconsidered based on the

additional evidence.

• In 5 of the 79 denied cases that we reviewed, VA had not requested records

from physicians who had treated the veteran since leaving military service.

For one case, VA officials stated that an attempt was made to obtain the

evidence but the doctor failed to respond. In three cases officials stated

that the medical records were not obtained due to error. According to area

processing office officials, private medical records were not obtained in

the other case because the veteran visited the doctor after the presumptive

period.

• Although VA recognizes the importance of nonmedical objective

evidence—for example, work records and lay statements from

knowledgeable individuals—in supporting some undiagnosed illness

claims, VA’s standard compensation claim form does not request such

evidence. The form does ask veterans to identify individuals who know

about the veteran’s medical treatment while in the service; in many cases,

3

About one-half of the undiagnosed conditions that VA granted were found to be 10-percent disabling,

with the highest disability rating being 40 percent.

Page 5 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

however, the claimed undiagnosed illness was not treated in the service.

According to VA officials, the form was designed to obtain evidence about

typical illnesses and injuries that usually occur while veterans are in the

service as opposed to Persian Gulf illnesses that can become manifest

after veterans leave military service.

• While the VA form does not specifically request nonmedical information,

about 15 percent of the veterans did provide VA with the names of

individuals who were knowledgeable about their claimed illness. However,

VA did not obtain statements from these individuals.

Officials at the area processing offices cited several reasons why lay

statements were not obtained or used. These reasons include the veteran’s

failure to provide a complete address for the knowledgeable individual

and that the evidence fell outside the presumptive period. In one case, an

area processing office official stated that VA should have obtained the

statements. While the head of the claims processing unit at one area

processing office questioned the value of lay statements and whether VA

was responsible for obtaining them, VA central office officials

acknowledged that VA was responsible for obtaining lay statements and a

central office official told us that statements would be obtained for the

cases that we identified and that the claims would be reconsidered after

the statements were obtained.

• After the Congress passed legislation allowing compensation for

undiagnosed illnesses, VA reexamined all completed Gulf War claim files to

determine if compensation was warranted. In some of these cases that we

reviewed, there was no indication that VA had informed the veteran after

the legislation about the specific types of medical and nonmedical

evidence that could be submitted to support the claim. According to VA

officials, VA had decided to provide this information to the veterans on a

case-by-case basis.

VA’s central office acknowledged that the existing procedures to develop

undiagnosed illness claims are not adequate and that area processing

offices could do a better job of requesting both medical and nonmedical

evidence from veterans in support of undiagnosed illness claims. VA has

taken a step to provide better information to veterans regarding evidence

to support undiagnosed illness claims. VA has developed a letter that

clearly states the types of medical and nonmedical evidence that can be

used to support these claims. VA is now sending this letter to all veterans

who file undiagnosed illness claims.

Page 6 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

Veterans Did Not Always

Provide Needed Support

for Claims

In the denied cases that we reviewed, even when VA followed all

appropriate procedures to develop claims, the veterans did not always

provide the necessary evidence that would allow their claims to be

granted.

• Only 30 percent of the veterans in the denied cases that we reviewed

provided evidence that they had sought medical treatment for the claimed

undiagnosed condition after leaving the service—some veterans said that

they could not afford medical treatment from private providers while

others indicated that they were too busy to see a physician.

• About 40 percent of the veterans in the denied cases that we reviewed

were informed that their denied undiagnosed illness claims would be

reconsidered if additional evidence was submitted; and VA thoroughly

described the evidence that would be acceptable. However, only 4 percent

of these cases included any additional information from the veteran.

• Twenty-three percent of the veterans in the denied cases that we reviewed

did not show up for all the scheduled examinations. As a result, VA was

unable to identify and thoroughly evaluate the claimed disabling

conditions.

VA Reports Overstate

Presumptive Period as

Reason for Denial

VA does not always correctly categorize the reason undiagnosed illness

claims were denied. VA requires each of its area processing offices to

record the reason that undiagnosed illness claims were denied. Reported

results are compiled and presented periodically to the Congress.

According to VA, most claims are denied because the claimed disability did

not become manifest on active duty in the Persian Gulf or during the

2-year presumptive period. Table 1 shows the latest data submitted by VA.

Table 1: Reasons VA Denied 7,424

Persian Gulf Undiagnosed Illness

Claims as of February 1996

Reason for denial Number Percent

Illness diagnosed 685 9.23

Illness not chronic 177 2.38

Due to other cause 29 0.39

Not manifest during service in the Gulf or during the 2-year

presumptive period 4,640 62.50

Not shown by evidence 1,776 23.92

Less than 10-percent disabling 117 1.58

Of the denied claims that we reviewed, most—68 percent—had been

categorized by VA as being denied because the claimed illness did not

become manifest on active duty or during the presumptive period.

Page 7 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
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However, in most of these cases, VA had explained in its decision letter to

the veteran that insufficient evidence was presented to demonstrate that

the claimed conditions existed, was chronic, or was disabling to a

compensable degree of 10 percent or more.

By failing to appropriately categorize denied claims, VA may be creating

the impression that many veterans with otherwise compensable

disabilities do not receive benefits solely as a result of the presumptive

period. Our review suggests that if the presumptive period was extended,

VA would still be required to deny the claims unless the veteran provided

additional evidence regarding the chronic nature or disabling impact of the

illness. VA officials acknowledged that their current reports could be

misinterpreted. They told us that VA will assess the extent of the problem

and take the necessary corrective action.

Agency Comments

and Our Evaluation

We obtained comments on a draft of this report from VA officials, including

the Deputy Under Secretary for Benefits. The officials generally agreed

with our findings and noted that the agency is taking additional steps to

address the concerns that we raised. Specifically, VA officials reiterated

their commitment to providing veterans with better information regarding

acceptable evidence to support undiagnosed illness claims and to more

accurately categorize the reasons that claims are denied. The officials told

us that VA’s central office will also undertake additional claims reviews to

ensure that field offices are following all appropriate procedures. VA’s

comments included some technical changes, primarily for clarification,

which we incorporated in this report as appropriate.

Page 8 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
B-265991 

As arranged with your office, unless you announce its contents earlier, we

plan no further distribution of this report until 7 days after the date of this

letter. At that time, we will send copies to the Chairman, Senate

Committee on Veterans’ Affairs; the Secretary of Veterans Affairs; and

other interested parties.

This work was performed under the direction of Irene Chu, Assistant

Director, Health Care Delivery and Quality Issues. If you or your staff have

any questions, please contact Ms. Chu or me on (202) 512-7101. Other

major contributors to this report are listed in appendix II.

Sincerely yours,

David P. Baine

Director, Health Care Delivery

 and Quality Issues

Page 9 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
Contents

Letter 1

Appendix I 

Scope and

Methodology

12

Appendix II 

Major Contributors to

This Report

13

Table Table 1: Reasons VA Denied 7,424 Persian Gulf Undiagnosed

Illness Claims as of February 1996

7

Abbreviations

VA Department of Veterans Affairs

VARO Department of Veterans Affairs Regional Office

Page 10 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
Page 11 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
Appendix I 

Scope and Methodology

To identify the evidence standards that VA established to process Persian

Gulf War claims, we visited the VA central office in Washington, D.C., and

two of the four area processing offices that VA designated as responsible

for processing undiagnosed illness claims—Louisville, Kentucky, and

Nashville, Tennessee (which together processed 72 percent of

undiagnosed illness claims). We also conducted telephone discussions

with officials at the other two area processing offices—Phoenix, Arizona,

and Philadelphia, Pennsylvania. We also obtained pertinent documents

and records from these offices.

To obtain information about the undiagnosed illness disability

compensation claims, we statistically sampled 79 of the 4,990 claims that

VA had denied as of September 21, 1995. We randomly selected the claims

from VA’s database of completed Persian Gulf War claims. Our sample size

provides a 90-percent confidence level that the characteristics of our

sample match the total population of denied claims within a specified

error rate. The error rate was no greater than 11 percent.

We also reviewed the claims files of 26 randomly selected veterans from

the 273 whose claims for undiagnosed illnesses had been granted as of

September 21, 1995. We selected four granted claims each from the

Nashville, Louisville, and Philadelphia offices and 14 from the Phoenix

office. We selected additional claims from the Phoenix office because it

had processed 32 percent of all granted claims although it only processed

11 percent of all Persian Gulf claims. This was not a statistical sample;

therefore, the results cannot be projected to the universe of granted

claims. Instead, we reviewed these claims to allow a comparison with the

denied claims.

In conducting our samples we reviewed documents pertinent to our work,

including the veterans’ application forms; letters from VA to the veterans

about additional evidence; medical examinations; and rating statements

with the letters containing VA’s decisions. Data about all Persian Gulf War

illnesses and other information were abstracted from those documents

and entered into a database for analysis.

The purpose of our review of the denied and granted claim files was to

identify the evidence contained therein and gain additional information on

VA’s reasons and bases for denying or granting the claims. We made no

effort to assess the appropriateness of VA’s decisions. We performed our

review between August 1995 and March 1996 in accordance with generally

accepted government auditing standards.

Page 12 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
Appendix II 

Major Contributors to This Report

Richard Wade, Evaluator-in-Charge

Jon Chasson, Senior Evaluator

Robert DeRoy, Assistant Director, Data Analysis and Evaluation Support

Cynthia Forbes, Senior Evaluator

Michael O’Dell, Senior Social Science Analyst

Susan Poling, Assistant General Counsel

Pamela A. Scott, Communications Analyst

(107543) Page 13 GAO/HEHS-96-112 Persian Gulf Undiagnosed Illness Claims
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