Veterans' Benefits: Quality Assurance for Disability Claims and Appeals Processing Can Be Further Improved
Released: 2002-08-26T00:00:00

Letter

Background

VA has two basic cash disability benefits programs. The compensation program pays monthly benefits to eligible veterans who have service- connected disabilities (injuries or diseases incurred or aggravated while on active military duty). The payment amount is based on the veteran’s degree of disability, regardless of employment status or level of earnings. By contrast, the pension program assists permanently and totally disabled wartime veterans under age 65 who have low incomes and whose disabilities are not service-connected. The payment amount is determined on the basis of financial need.

VBA and the Board process and decide veterans’ disability claims and appeals on behalf of the Secretary. The claims process starts when veterans submit claims to one of VBA’s 57 regional offices. (See app. I for the overall flow of claims and appeals processing.) By law, regional offices must assist veterans in supporting their claims. For example, for a compensation claim, the regional office obtains records such as the veteran’s existing service medical records, records of relevant medical treatment or examinations provided at VA health-care facilities, and other relevant records held by a federal department or agency. If necessary, the regional office arranges a medical examination for the claimant or obtains a medical opinion about the claim. The regional office adjudicator then must analyze the evidence for each claimed impairment (veterans claim an average of about five impairments per claim); determine whether each claimed impairment is service-connected (VA grants service-connection for an average of about three impairments per claim); apply VA’s Rating Schedule which provides medical criteria for rating the degree to which each service-connected impairment is disabling (disability ratings can range from zero to 100 percent, in 10-percent increments); determine the overall disability rating that results from the combination of service-connected impairments suffered by the veteran; and notify the veteran of the decision.

If a veteran disagrees with the regional office’s decision, he or she begins the appeals process by submitting a written Notice of Disagreement to the regional office. During fiscal years 1999-2000, the regional offices annually made an average of about 616,000 decisions involving disability ratings, and veterans submitted Notices of Disagreement in about 9 percent of these decisions. Veterans can disagree with decisions for reasons other than the outright denial of benefits that occurs, for example, in a compensation case when a regional office decides an impairment claimed by a veteran is not service-connected. The veteran also may believe the severity rating assigned to a service-connected impairment is too low and ask for an increase in the rating.

In response to a Notice of Disagreement, the regional office provides a further written explanation of the decision, and if the veteran still disagrees, the veteran may appeal to the Board. During fiscal years 1999- 2000, about 48 percent of the veterans who filed Notices of Disagreement in decisions involving disability ratings went on to file appeals with the Board. In fiscal year 2001, VBA began nationwide implementation of the Decision Review Officer position in its regional offices. Now, before appealing to the Board, a veteran may ask for a review by a Decision Review Officer, who is authorized to grant the contested benefits based on the same case record that the regional office relied on to make the initial decision. VBA believes this process will result in fewer appeals being filed with the Board.

Located in Washington, D.C., the Board is an administrative body whose members are attorneys experienced in veterans’ law and in reviewing benefits claims. The Board’s members are divided into four decision teams, with each team having up to 15 Board members and 61 staff attorneys. Each team has primary responsibility for reviewing the appeals that originate in an assigned group of regional offices. Board members’ decisions must be based on the law, regulations, precedent decisions of the courts, and precedent opinions of VA’s General Counsel. During the Board’s appeals process, the veteran or the veteran’s representative may submit new evidence and request a hearing.

During fiscal years 1999 and 2000, for all VA programs, the Board annually decided an average of about 35,700 appeals, of which about 32,900 (92 percent) were disability compensation cases. The average appealed compensation case contains three contested issues. As a result, in some cases, the Board member may grant the requested benefits for some issues but deny the requested benefits for others. During fiscal years 1999 and 2000, the Board in its initial decisions on appealed compensation cases granted at least one of the requested benefits in about 24 percent of the cases. In some instances, the Board member finds a case is not ready for a final decision and returns (or remands) the case to the regional office to obtain additional evidence and reconsider the veteran’s claim. During fiscal years 1999 and 2000, respectively, the Board in its initial decisions on appealed compensation cases remanded 38 percent and 34 percent of the cases. After obtaining additional evidence for remanded cases, if the regional office still denies the requested benefits, it resubmits the case to the Board for a final decision.

If the Board denies benefits or grants less than the maximum benefit available under the law, veterans may appeal to the U. S. Court of Appeals for Veterans Claims. The court is not part of VA and not connected to the Board. During fiscal years 1999 and 2000, veterans filed appeals with the court in an estimated 10 percent of the Board’s decisions. Unlike the Board, the court does not receive new evidence, but considers the Board’s decision, briefs submitted by the veteran and VA, oral arguments, if any, and the case record that VA considered and that the Board had available. The court may dismiss an appeal on procedural grounds such as lack of jurisdiction, but in the cases decided on merit, the court may affirm the Board’s decision (deny benefits), reverse the decision (grant benefits), or remand the decision back to the Board for rework. During fiscal years 1999 and 2000, the court annually decided on merit an average of about 1,800 appealed Board decisions, and in about 67 percent of these cases, the court remanded or reversed the Board’s decisions in part or in whole.Under certain circumstances, a veteran who disagrees with a decision of the court may appeal to the U.S. Court of Appeals for the Federal Circuit and then to the Supreme Court of the United States.

The Board Understates Its Accuracy and Does Not Capture Certain Data for Improving Quality

In fiscal year 1998, the Board established the first quantitative quality assurance program to evaluate and score the accuracy of its decisions and to collect data to identify areas where the quality of decision-making needs improvement. The accuracy measure used by the Board understates its true accuracy rate because the Board’s accuracy rate calculations include certain deficiencies that would not result in either a reversal or a remand by the court. Even so, the Board’s quality assurance program does not capture certain data that potentially could help improve the quality of the Board’s decisions. Such data include information identifying the specific medical issues involved in cases where a disability decision was judged as being in error. Having such data could enhance the Board’s ability to target training for its decision makers.

The Board Established Its First Quantitative Quality Assurance Program in 1998

On the basis of the results of the quality assurance program it established in fiscal year 1998, the Board estimated that 89 percent of its decisions were accurate (or “deficiency-free”). Using these results as a baseline, VA established performance accuracy goals for the Board. One of the Board’s strategic performance goals is to make deficiency-free decisions 95 percent of the time. To calculate its estimated overall accuracy rate, the Board does quality reviews of selected Board decisions. We reviewed the Board’s methods for selecting random samples and calculating accuracy rates and concluded that the number of decisions reviewed by the Board was sufficient to meet the Board’s goal for statistical precision in estimating its accuracy rate. However, we brought to the Board’s attention some issues that caused the Board to fall short of proper random sampling and accuracy rate calculation methods, such as not ensuring that decisions made near the end of the fiscal year are sampled or that the results from quality reviews are properly weighted in the accuracy rate calculation formula. We do not believe the overall accuracy rate reported by the Board for fiscal year 2001 would have been materially different if these methodological issues had been corrected earlier; however, if not corrected, these issues potentially could lead to misleading accuracy rate calculations in the future. The Board agreed in principle to correct these issues. As of June 2002, the Board had not yet instituted corrective actions.

The Board’s Actual Level of Accuracy Is Higher Than Reported

According to VA’s performance reports, the Board has come close but has not achieved its annual interim goals for accuracy (see table 1). However, in calculating its reported accuracy rates, the Board includes deficiencies that are not “substantive”—that is, they would not be expected to result in either a remand by the court or a reversal by the court. Consequently, the reported accuracy rates understate the Board’s level of accuracy that would result if only substantive deficiencies were counted in the calculation.

Under its quality assurance program, the Board’s quality reviewers assess the accuracy of selected decisions on the basis of six critical areas (see table 2). One error (or deficiency) in any of these six areas means that a decision fails the quality test. However, according to the Board, all six areas would include certain deficiencies that are not substantive. In particular, according to the Board, most deficiencies in the “format” category are not substantive. In fiscal year 2001, the format category accounted for about 38 percent of all recorded deficiencies. At our request, the Board recalculated its accuracy rate for fiscal year 2001, excluding format deficiencies, and the resulting accuracy rate was 92 percent, as compared with the reported accuracy rate of 87 percent. Excluding all other nonsubstantive deficiencies presumably would have resulted in an even higher accuracy rate. In contrast with the Board, beginning in fiscal year 2002, VBA no longer includes nonsubstantive deficiencies in its accuracy rate calculations; however, it continues to monitor them. VBA took this action based on a recommendation by the 2001 VA Claims Processing Task Force, which said that mixing serious errors with less significant deficiencies can obscure what is of real concern.

The Board’s quality review program subdivides the six critical areas shown in table 2 into 31 subcategories. For example, if a quality reviewer classifies an error as stemming from “reasons and bases,” the reviewer must then indicate whether the error was due to misapplying legal authority, failing to apply appropriate legal authority, using an incorrect standard of proof, or providing an inadequate explanation for the decision. This information is recorded in the Board’s quality review database, providing the Board with data that can be analyzed to identify training needed to improve quality.

However, the Board does not record in its quality review database any information on the specific issue that prompted the appeal (such as whether a disability is service-connected) or the specific medical impairment to which an error is related. For example, a quality reviewer might find an error in a Board decision for an appeal that involved four separate medical impairments—two for which the veteran had requested service connection and two others for which he had requested a disability rating increase. On the basis of information that the quality review database currently captures, however, the Board could not determine which of the four impairments the error was related to, nor could the Board determine whether the error was related to a request for service- connection or an increased disability rating.

This is not the case, however, for Board decisions remanded by the Court of Appeals for Veterans Claims. For these cases, the Board maintains a separate database with information on the reasons that the court remands decisions back to the Board for rework. For each issue that the court remands in a compensation case, the Board records in the database such information as: (1) whether the issue involved a request for service- connection or an increased rating, (2) the diagnostic code of the impairment involved in each issue, and (3) the reason for the remand. According to Board officials, being able to analyze the court’s reasons for remands by type of decisional issue and type of impairment enhances the Board’s ability to reduce remands from the court through appropriate training.

VBA and the Board recognize that in some cases, different adjudicators reviewing the same evidence can make differing judgments on the meaning of the evidence, without either decision necessarily being wrong. In such cases, VBA and the Board instruct quality reviewers not to record an error. A hypothetical case provided by the Board furnishes an example. In this case, a veteran files a claim in 1999 asserting he suffered a back injury during military service but did not seek medical treatment at that time. One of the veteran’s statements says he injured his back during service in 1951, but another says he injured his back in 1953. An adjudicator may find that this discrepancy in dates adversely affects the claimant’s credibility about whether an injury actually occurred in service, but the quality reviewer may consider the discrepancy to be insignificant. Where such judgments are involved, the Board’s and VBA’s quality review programs recognize that variations in judgment are to be expected and are acceptable as long the degree of variation is within reason. (App. II provides other examples of difficult judgments that could result in decision-making variations and explains VA’s “benefit-of-the-doubt” rule.)

The Board and VBA, however, differ in their approaches to collecting information about cases where this type of variation occurs. In such instances, the Board’s quality reviewers note why they believe an alternative decision could have been made and send the explanation to the deciding Board member. However, they do not enter any of this information in the quality review database. In contrast, VBA recently instructed its quality reviewers to enter such information in the VBA quality review database, even though no error is recorded in the database. VBA believes that by identifying and analyzing cases in which quality reviewers believed the adjudicator’s judgment was pushing against the boundary of reasonableness, it potentially can identify opportunities to improve the quality of decision making by improving training.

VA Does Not Systematically Assess Consistency of Decision Making

Even though evidence suggests decision making across regional office and Board adjudicators may not be consistent, VA does not systematically assess decision making consistency to determine the degree of variation that occurs for specific impairments and to provide a basis for identifying steps that could be taken, if considered necessary, to reduce such variation. In its 2003 performance plan, VA acknowledged that veterans are concerned about the consistency of disability claims decisions across the 57 regional offices. In a nationwide comparison, VBA projected in its fiscal year 2001 Annual Benefits Report that the average compensation payments per disabled veteran in fiscal year 2002 would range from a low of $5,783 in one state to a high of $9,444 in another state. According to a VBA official, this disparity in average payments per veteran might be due in part to demographic factors such as differences in the average age of veterans in each state. However, this disparity in average payments per veteran also raises the possibility that when veterans in the same age group submit claims for similar medical conditions, the regional office in one state may tend to give lower disability ratings than the regional office in another state.

Indeed, in 1997, the National Academy of Public Administration reviewed disability claims processing and said VA needed to identify the degree of decision-making variation expected for specific medical issues, set consistency standards, and measure the level of consistency as part of the quality review process or through testing of control cases in multiple regional offices. Furthermore, in 2001, VA’s Claims Processing Task Force said there was an apparent lack of uniformity among regional offices in interpreting and complying with directives from VA headquarters and that VA’s regulations and the procedures manual for regional offices were in dire need of updating. The task force concluded that there was no reasonable assurance that claims decisions would be made as uniformly and fairly as possible to the benefit of the veteran. Even though such concerns and issues exist, VA does not systematically assess the decision- making consistency of regional office adjudicators.

Similarly, VA does not assess consistency between decisions made by regional offices and the Board even though evidence suggests this issue may warrant VA’s attention. Because veterans may submit new evidence during the appeals process, one might assume that the Board generally grants benefits denied by regional offices due to the impact of such new evidence. However, an analysis in 1997 of about 50 decisions in which the Board had granted benefits previously denied by regional offices yielded a different viewpoint. Staff from both VBA and the Board reviewed these cases and concluded that most of these Board decisions to grant benefits had been based on the same evidence that the regional offices had considered in reaching their decisions to deny benefits. The reviewers characterized the reason for the Board members’ decisions to grant benefits as a difference of opinion between the Board members and regional office adjudicators in the weighing of evidence. Furthermore, even in remanded compensation cases for which regional offices have obtained new evidence in accordance with the Board’s remand instructions and then again denied the benefits, the Board generally has granted benefits in about 26 percent of these cases after they have been resubmitted for a final decision. This seems to indicate that, in these particular cases, Board members in some way differed with regional office adjudicators on the impact of the new evidence obtained by the regional offices before resubmitting the remanded cases to the Board.

Available evidence also provides indications that the issue of variations in decision making among the Board members themselves may warrant VA’s attention in studies of consistency. Historically, there have been variances in the rates at which the Board’s four decision teams have remanded decisions to regional offices for rework. No systematic study has been done to explain the variances in remand rates. Board officials said that it is their perception that the remand rates vary among the Board’s decision teams because the quality of claims processing varies among the regional offices for which each team is responsible.

Similar concerns about consistency of claims adjudication in the Social Security Administration (SSA) have prompted SSA to begin taking steps to assess consistency issues in its disability program. As we reported in 1997, SSA’s primary effort to improve consistency has focused on decision- making variations between its initial and appellate levels. To gather data on variations between these two levels, SSA instituted a system in 1993 under which it selects random samples of final decisions made by administrative law judges and reviews the entire decisional history of each case at both the initial and appellate levels. The reviewers examine adjudicative and procedural issues to address broad program issues such as whether a claim could have been allowed earlier in the process. Data captured through this system have provided a basis for taking steps to clarify decision-making instructions and provide training designed to improve consistency between the initial and appellate levels. However, no systematic evaluations have been done to determine the effectiveness of these actions. In its January 2001 disability management plan, SSA said that it needed to take further steps to promote uniform and consistent disability decisions across all geographic and adjudicative levels.

Conclusions

Opportunities exist to improve the quality of the Board’s reporting of accuracy and decision making. The Board includes nonsubstantive deficiencies in its accuracy rate calculation. By doing so, the Board may be obscuring what is of real concern. In addition, the Board’s quality assurance database does not capture data on specific medical disability issues related to the reasons for errors found in Board decisions. Also, in contrast with VBA, the Board’s quality assurance program does not collect information on cases in which quality reviewers do not charge errors but have differences of opinion with judgments made by Board members. We believe that analysis of such data could lead to improvements in quality through improved training or by clarifying regulations, procedures, and policies.

Furthermore, because variations in decision making are to be expected due to the difficult judgments that adjudicators often must make, one must ask the questions: For a given medical condition, how much variation in decision making exists and does the degree of variation suggest that VA should take steps to reduce the level of variation? VA, however, does not assess variation in decision making. None of the quality review efforts of either VBA or the Board are designed to systematically assess the degree to which veterans with similar medical conditions and circumstances may be receiving different decisional outcomes or to help identify steps that could reduce such variation if necessary. Without ongoing systematic assessments of consistency across the continuum of decision making, VA cannot adequately assure veterans that they can reasonably expect to receive consistent treatment of their claims across all decision-making levels in VA.

Recommendations for Executive Action

We recognize that our recommendations will have to be implemented within the context of VA’s current major efforts to reduce a large and persistent backlog of disability claims and appeals and to reduce the average processing time. Nevertheless, we believe it is critical that VA take the necessary steps to support improvements in training and in regulations, procedures, or policies that could enhance the quality of disability decision making across the continuum of adjudication and to help provide adequate assurance to veterans that they will receive consistent and fair decisions as early as possible in the process. Indeed, maintaining and improving quality should be of paramount concern while implementing a major effort to reduce backlogs and processing time.

Accordingly, we recommend that the Secretary of VA direct the Chairman of the Board of Veterans’ Appeals to: Revise the quality assurance program so that, similar to VBA, the calculation of accuracy rates will take into account only those deficiencies that would be expected to result in a reversal of a Board decision by the U.S. Court of Appeals for Veterans Claims or result in a remand by the court.

Revise the Board’s quality assurance program to record information in the quality review database that would enable the Board to systematically analyze case-specific medical disability issues related to specific errors found in Board decisions in the same way that the Board is able to analyze the reasons that the court remands Board decisions.

Monitor the experience of VBA’s quality assurance program in collecting and analyzing data on cases in which VBA’s quality reviewers do not record errors but have differences of opinion with regional office adjudicators in the judgments made to reach a decision. If VBA finds that the analysis of such data helps identify training that can improve the quality of decision making, the Board should test such a process in its quality assurance program to assess whether it would enable the Board to identify training that could improve the quality of Board decisions.

We also recommend that the Secretary direct the Under Secretary for Benefits and the Chairman of the Board of Veterans’ Appeals to jointly establish a system to regularly assess and measure the degree of consistency across all levels of VA adjudication for specific medical conditions that require adjudicators to make difficult judgments. For example, VA could develop sets of hypothetical claims for specific medical issues, distribute such hypothetical claims to multiple adjudicators at all decision-making levels, and analyze variations in outcomes for each medical issue. Such a system should provide data to determine the degree of variation in decision making and provide a basis to identify ways, if considered necessary, to reduce such variation through training or clarifying and strengthening regulations, procedures, and policies. Such a system should also assess the effectiveness of actions taken to reduce variation. If departmental consistency reviews reveal any systematic differences among VA decision makers in the application of disability law, regulations, or court decisions, the Secretary should, to the extent that policy clarifications by VBA cannot resolve such differences, direct VA’s General Counsel to resolve these differences through precedent legal opinions if possible.

Agency Comments and Our Evaluation

We received written comments on a draft of this report from VA (see app. III). In its comments, VA concurred fully or in principle with our recommendations. With regard to our first recommendation, VA said that the Board intends to revise its quality review system to count only substantive errors for computational and benchmarking purposes but will continue to track all errors. On the basis of VA’s comments, we also modified the report to accurately reflect the standard of review employed by the U.S. Court of Appeals for Veterans Claims in reviewing Board decisions. With regard to our second recommendation, VA said that it would use its Veterans Appeals Control Locator System to gather information on case-specific medical disability issues related to specific errors found in Board decisions. VA questioned our basis for concluding that tracking such information will yield useful data for improving the adjudication system. As stated in the draft report, we based our recommendation on the fact that the Board has already concluded that such information is beneficial for analyzing the reasons for remands from the Court of Appeals for Veterans Claims. With regard to our third recommendation, VA said representatives of the Board and VBA will meet so that a system may be established for the Board to access and review VBA’s methodology for assessing, reporting, and evaluating instances of “difference of opinion” between the quality reviewer and the decision maker.

In its comments, VA concurred in principle with our fourth recommendation. VA agreed that consistency is an important goal and acknowledged that it has work to do to achieve it. However, VA was silent on how it would measure consistency for specific medical conditions that require adjudicators to make difficult judgments. Instead, VA described the kinds of actions underway that it believes will generally reduce inconsistency. While we support these efforts, we maintain that without a way to evaluate and measure consistency, VA will be unable to determine the extent to which such efforts actually improve consistency of decision- making across all levels of VA adjudication now and over time. Neither will VA have information needed to identify ways to reduce decision- making variations for specific medical conditions, if considered necessary.

As agreed with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. At that time, we will send copies of this report to the Secretary of the Department of Veterans Affairs, appropriate congressional committees, and other interested parties. We will also make copies available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov.

If you have questions about this report, please call me on (202) 512-7101 or Irene Chu on (202) 512-7102. Other key contributors were Ira Spears, Steve Morris, Patrick diBattista, and Mark Ramage.

Appendix I: Steps in the Disability Claims and Appeals Process

57 Regional Offices Decide Claims and Notify Veterans of Decisions (estimated disposition of 100,000 compensation claims filed with regional offices)

1. Veterans either agree with regional offices decisions 2. Veterans submit Notices of Disagreement to regional or take no further action in 90,880 cases. offices in 9,120 cases. In 3,657 of these cases, veterans go on to file appeals with the Board.

Board of Veterans' Appeals Board Members Review Regional Office Decisions Appealed by Veterans (estimated disposition of 3,657 compensation cases appealed to Board)

3. Board remands 1,311 cases to regional 4. Board grants at least one requested offices to develop further evidence and reconsider their decisions (Board remands 211 of these cases twice). benefit in 1,153 cases (Board makes 269 of these grants after regional offices resubmit remanded cases).

5. Board denies all benefits in 1,956 cases (Board makes 494 of these denials after regional offices resubmit remands).

6. Regional offices obtain more evidence 7. Regional offices obtain 9. Veterans appeal 307 but deny requested benefits in 839 cases and resubmit these cases to the Board for a final decision (of the 211 remanded twice, regional offices deny benefits in 135 and resubmit them to Board). more evidence and grant requested benefits in 339 cases (47 of these 339 grants occur after the second remand).

8. Veterans withdraw or regional offices close 209 cases (28 of these 209 withdrawals or closures occur after second remand). cases to U.S. Court of Appeals for Veterans Claims.

U.S. Court of Appeals for Veterans Claims Court Reviews Board Decisions Appealed by Veterans (estimated disposition of 307 compensation cases appealed to the court)

10. Court dismisses 74 cases on 11. Court affirms Board decisions in whole 12. In whole or in part, Court reverses Board procedural grounds. in 77 cases (all requested benefits denied). decisions (grants requested benefits) or remands Board decisions in 156 cases.

U.S. Court of Appeals for the Federal Circuit. the cases remanded by the court.

The estimated disposition by VA’s regional offices of the 100,000 claims (in boxes 1 and 2) is based on data for claims involving disability ratings for fiscal years 1997 to 2000. During those years, veterans submitted Notices of Disagreement in about 9 percent of the regional office decisions and went on to file appeals with the Board in about 40 percent of the cases in which they had submitted such notices.

On the basis of Board data for fiscal years 1999 and 2000, in its initial decisions on appealed compensation cases, the Board: (1) granted at least one of the requested benefits in about 24 percent of the cases, (2) denied all requested benefits in about 40 percent of the cases, and (3) remanded about 36 percent of the cases to regional offices for rework. After obtaining the additional evidence required by the Board for remanded cases, the regional offices granted requested benefits in about 22 percent of the remanded cases and denied requested benefits in 64 percent of the cases. After regional offices resubmitted denied cases to the Board for a final decision, the Board granted at least one of the requested benefits in about 26 percent of the cases, denied all benefits in about 49 percent, and remanded about 25 percent once again to regional offices for further rework. For this illustration, we assumed that the Board did not remand a case more than two times.

The estimate of 307 cases appealed to the U.S. Court of Appeals for Veterans Claims (in box 9), the court’s estimated disposition of these 307 cases (in boxes 10, 11, 12), and the estimated number of decisions appealed to the U.S. Court of Appeals for the Federal Circuit (in box 13) are based on fiscal years 1999 and 2000 data from the court’s annual reports.

Appendix II: Board of Veterans’ Appeals Illustrations of Difficult Judgments Resulting in Decision-Making Variations

Appendix II: Board of Veterans’ Appeals Illustrations of Difficult Judgments Resulting in Decision-Making Variations Examples of difficult judgments To be granted benefits for post-traumatic stress disorder, a veteran’s claim must have credible evidence that a stressor occurred during military service. Assume the record shows a claimant served in Vietnam as a supply specialist, and he identified mortar attacks as a stressor. Reports prepared by his military unit in Vietnam indicate a single enemy mortar attack occurred where the claimant was stationed. The claimant’s testimony was vague about the number and the time of the attacks. One adjudicator may rely on the unit’s reports and conclude the claimant engaged in combat and is entitled to have his lay statements accepted without further corroboration as satisfactory evidence of the in-service stressor. Another adjudicator may conclude that the claimant is not credible as to exposure to enemy fire and require other credible supporting evidence that the in-service stressor actually occurred. Assume an appeal for either service connection or a higher disability rating has two conflicting medical opinions, one provided by a medical specialist who reviewed the claim file but did not actually examine the veteran and a second opinion provided by a medical generalist who reviewed the file and examined the veteran. One adjudicator could assign more weight to the specialist’s opinion, while another could find the generalist’s opinion to be more persuasive. Thus, depending on which medical opinion is given more weight, one adjudicator could grant the claim and the other deny it. Yet, a third adjudicator could find both opinions to be equally probative and conclude that VA’s “benefit-of-the-doubt” rule requires that he decide in favor of the veteran’s request for either service-connection or a higher disability rating. Under the benefit-of-the-doubt rule, if an adjudicator concludes that there is an approximate balance between the evidence for and the evidence against a veteran’s claim, the adjudicator must decide in favor of the veteran. The Rating Schedule does not provide objective criteria for rating the degree to which certain spinal impairments limit a claimant’s motion. The adjudicator must assess the evidence and draw a conclusion as to whether the limitation of motion falls into one of three severity categories: “slight, moderate, or severe.” Similarly, in assessing the severity of incomplete paralysis, the adjudicator must draw a conclusion as to whether the veteran’s incomplete paralysis falls into one of three severity categories: “mild, moderate, or severe.” In each case, each severity category in itself encompasses a range of severity, and the judgment as to whether a claimant’s condition is severe enough to cross over from one severity range into the next could vary in the minds of different adjudicators.

The Rating Schedule provides a formula for rating the severity of a veteran’s occupational and social impairment due to a variety of mental disorders. However, the formula actually is a nonquantitative, behaviorally oriented framework for guiding adjudicators in making judgments and drawing conclusions as to which of the following characterizations best describes the degree to which a claimant is occupationally and socially impaired: (1) totally impaired; (2) deficient in most areas such as work, school, family relations, judgment, thinking, or mood; (3) reduced reliability and productivity; (4) occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; (5) mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms can be controlled by continuous medication, and (6) not severe enough to interfere with occupational or social functioning or to require continuous medication.

Appendix III: Comments from the Department of Veterans Affairs