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M21-1, Part IV, Subpart ii, Chapter 1, Section A – Developing Compensation Claims, to Include Claims Filed Under 38 U.S.C. 1151

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2

1.  General Information on Developing Compensation Claims, to Include Claims Filed Under 38 U.S.C. 1151


Change Date

August 1, 2016

IV.ii.1.A.1.a.  General Overview of the Compensation Claims Development Process

The table below provides
  • a general overview of actions undertaken by the claims processor in the course of compensation claims develpment, and
  • references comprising more detailed guidances on the stages and topics described.
Stage
Description
Reference(s)
1
Review for receipt of a substantially complete application.
2
Review or development for evidence of service verification.
3
Development for service treatment, dental, and/or personnel records necessary to substantiate the claim.
4
Issuance of a standard Section 5103 notice to the claimant, if necessary.
5
Development for information necessary to establish entitlement to additional compensation for dependents.
6
Development for any post-service medical evidence, Federal and/or non-Federal, necessary to substantiate the claim.
7
Review of available medical and lay evidence to determine if an examination and/or medical opinion is needed.
8
Referral of the claim to the rating activity for a partial or final decision.

2.  Developing Claims Filed Under 38 U.S.C. 1151


Introduction

This topic contains information on developing claims filed under 38 U.S.C. 1151, including

Change Date

April 18, 2018

IV.ii.1.A.2.a.  General Information About Claims Filed Under 38 U.S.C. 1151

38 U.S.C. 1151 provides for the payment of compensation for additional disability or death attributable to
  • Department of Veterans Affairs (VA)
    • hospital care
    • medical or surgical treatment, or
    • examination
  • participation in vocational rehabilitation training, or
  • participation in compensated work therapy.
Disabilities and/or causes of death recognized under this provision of law are compensated “as if” service-connected (SC), but are not actually SC.

IV.ii.1.A.2.b.  Possible Sources of Information About the Incident

Documentary evidence pertinent to the incident upon which the claim is based may assume many possible forms, including

  • medical records
  • surgical records
  • hospital clinical records, and/or
  • nurses’ notes.

IV.ii.1.A.2.c.  Requesting Information From the Medical Facility

Follow the steps in the table below to obtain evidence and information from the medical facility identified as the site of the incident upon which the claim is based.
Step
Action
1
Retrieve any and all clinical reports, progress notes, and hospital summaries associated with the incident in question using the
2
Follow the instructions in M21-1, Part III, Subpart iii, 1.C.2.d to upload all pertinent records to the Veteran’s electronic claims folder.
3
As discussed in M21-1, Part III, Subpart iii, 1.C.2.d and e, request comprehensive evidence of the claimed incident using CAPRI’s electronic VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative and Adjudicative Action, request functionality.
Select the 7131 REQUEST tab in the patient’s CAPRI record, and cut and paste the following text into the COMMENTS field, populating necessary details about the claimant where appropriate:
We have received a claim from the person identified below for benefits under 38 U.S.C. 1151 based on alleged injury while at your facility.
Name:
File Number:
SSN:
Date of Birth:
The claimant alleges sustaining an injury to his/her[condition].  This injury occurred on [MM-DD-YYYY].
To assist us in making a determination, please furnish all of the following evidence, if available, for this patient for the period of medical care from [MM-DD-YYYY] to [MM-DD-YYYY]:
  • medical records
  • surgical records
  • hospital clinical records
  • nurses’ notes, and
  • any other documentation of patient injury.
Note:  The electronic VA Form 10-7131 in CAPRI supports text entry up to four pages and maintains tracking information regarding the status of requests.
References:   For more information on

IV.ii.1.A.2.d.  Quality Assurance Investigative Reports

Request quality assurance investigative reports only if the claimant
  • identifies these records as evidence necessary to substantiate their claim
  • identifies quality assurance records consistent with 38 U.S.C. 5103A(b)(1), and
  • furnishes sufficient information to locate the records consistent with 38 U.S.C. 5103A(c)(2).
Notes:
  • If the Veterans Health Administration (VHA) denies access to these records, then request an Office of General Counsel (OGC) review.
  • An OGC review is not appropriate when VHA denies access to these records because they are no longer available.
Reference:  For more information on the documents that qualify as quality assurance reports, see
4-18-18_Key-Changes_M21-1IV_ii_1_SecA.docx May 21, 2019 52 KB
Historical_M21-1IV_ii_1_SecA_11-4-15.docx May 21, 2019 59 KB
Historical_M21-1IV_ii_1_SecA_4-10-15-1.docx May 21, 2019 57 KB
8-1-16_Key-Changes_M21IV_ii_1_SecA.docx May 21, 2019 65 KB
Historical_M21-1IV_ii_1_SecA_4-10-15.docx May 21, 2019 57 KB
Transmittal-M21-1MRIV_ii_2TS.docx May 21, 2019 37 KB
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