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M21-1, Part V, Subpart i, Chapter 2 – Original Disability Pension Claims

Overview


In This Chapter

This chapter contains the following topics:
Topic
Topic Name
1
2
3
4
5

1.  General Information on Original Pension Claims


Introduction

This topic contains general information on eligibility and development for original pension claims, including

Change Date

May 2, 2018

V.i.2.1.a.  Elements of Pension Entitlement

In order to establish entitlement to Veterans Pension, the following elements must be shown:
  • qualifying service
  • a permanent and total (P&T) disability, or age of 65 years or older
  • countable income is below the maximum annual pension rate (MAPR), and
  • net worth limitations are met.
In order to establish entitlement to Survivors Pension, the following elements must be shown:
  • qualifying service
  • relationship to the Veteran
  • for a surviving spouse, the spouse is not remarried
  • for a surviving child, the child is unmarried and under 18, and
    • became permanently helpless before 18, or
    • is between 18 and 23 and is in school
  • countable income is below the MAPR, and
  • net worth limitations are met.
References:  For more information on

V.i.2.1.b.
Claims Processor Pension Development Guidelines

It is the responsibility of the claims processor to develop the evidence needed to establish entitlement to pension.  If a claim does not meet one or more of the eligibility requirements, deny the claim.  Do no develop or rate the claim.
Use the table below to find information on developing for each pension entitlement element.
For procedures for developing for …
See…
service
disability and age
Social Security disability
income and net worth
the willful misconduct aspect of an injury
relationship
Notes:
  • If a fully developed claim (FDC) that is accepted as substantially complete as noted in M21-1, Part I, 1.B.b requires additional development to the claimant, exclude the claim from the FDC Program and develop as necessary.  A claims processor cannot deny an FDC claim from a claimant that meets basic eligibility criteria without first developing for any information or evidence needed to support the claim.
  • If pension benefits cannot be granted or denied upon initial review of a claim, and a Section 5103 notice was not provided on the application, a Section 5103 notice must be included in any development letter.
  • A Veteran may need to report for any Department of Veterans Affairs (VA) medical examinations VA determines are necessary to decide his or her claim.

Reference:  For more information regarding FDC processing, see M21-1, Part III, Subpart i, 3.A and B.


V.i.2.1.c.  Veterans Pension Effective Dates and Payment Dates

In general, the effective date for an original Veterans Pension claim is the date the claim was received, per 38 CFR 3.400.  The payment date is the first day of the month following the date the claim was received, per 38 CFR 3.31.
References:  For more information on

V.i.2.1.d.  Survivors Pension Effective Dates and Payment Dates

Use the table below to determine the effective date and payment date of an original Survivors Pension claim.
If the application was received …
Then the effective date of the award is …
And the award payment date is …
within one year after the Veteran’s date of death
the first day of the month of death
the first day of the month following death.
more than one year after the Veteran’s date of death
the date the claim was received
the first day of the month following the date the claim was received.
Notes:
  • When the Survivors Pension award effective date is the first day of the month of the Veteran’s death, the first day of the initial year is the date of the Veteran’s death. VA does not count income that a surviving spouse or child received before the Veteran’s death.
  • In an original surviving spouse award, claims processors should also pay the month of death payment if it was not paid automatically. See 38 CFR 3.20 and M21-1, Part IV, Subpart iii, 3.A.5.
References:  For more information on

2.  Developing for P&T Disability and Age


Introduction

This topic contains information on developing for P&T disability and age, including

Change Date

February 19, 2019

V.i.2.2.a. When a Rating Determination of P&T Disability Is Not Required

A rating determination of P&T disability is not required to establish eligibility for Veterans Pension when a Veteran is
  • age 65 or older, or
  • presumed to be P&T disabled for pension purposes because he/she is
    • a patient in a nursing home for long-term care because of disability, or
    • disabled, as determined by the Commissioner of Social Security.
Note:  A medical foster home that VA has recognized and approved under 38 CFR 17.73 is equivalent to a nursing home.

V.i.2.2.b.  Acceptable Evidence of Age

Age is a factor in Veterans Pension claims.  If the Veteran is age 65 or older, a rating determination of P&T disability is not required.
If the date of birth as given by the Veteran agrees with other dates of birth shown in the records, no further development is necessary.  Otherwise, per 38 CFR 3.208, accept the youngest age shown in the records, pending receipt of acceptable evidence of birth as listed in 38 CFR 3.209.
Per 38 CFR 3.208, accept statements of age if they agree with those shown at enlistment by official records.  In addition, comparison may be made with statements made at other times for other purposes.
Reference:  For information on how to obtain acceptable evidence as listed in 38 CFR 3.209, see M21-1, Part III, Subpart iii, 1.A.

V.i.2.2.c.  Social Security Disability Evidence and Share Verification

If a Veteran is younger than age 65, but the Social Security Administration (SSA) has determined he or she is disabled, the Veteran may be presumed P&T disabled for pension purposes from the date of disability onset.
The information provided in the Share SSA Data screen may be used to determine eligibility for VA pension.  The following table provides information on handling SSA information obtained from Share.
Reference:  For more information on using Share, see the Share User Guide.
Social Security Title Status
Nature of Social Security Benefit
Title XVI Status has a Y indicator
Y in this field indicates that SSA data is available.  View the SSI BASIC INFO tab to determine if Social Security Income (SSI) is payable.  View the SSA BASIC INFO tab to review the DISABILITY ONSET DATE field.
Note: If a Veteran is found entitled to SSI, he or she meets the disability requirement for VA pension.
Title II Status has a Yindicator
Either Social Security retirement or Social Security disability is payable.
  • If the Veteran’s age is under 62, Social Security is based on a disability.  Presume that the VA pension disability requirement is met.
  • If the Veteran’s age is 62, 63 or 64, Social Security may be based on retirement or on disability.
    • If the date in the DATE OF INITIAL ENT field is exactly six full months after the date in the DISABILITY ONSET DATE field, then presume that the VA Pension disability requirement is met.
    • If the date in the DATE OF INITIAL ENT field is not shown or is not exactly six full months after the date in theDISABILITY ONSET DATE field, then develop to the claimant and the Social Security Administration (SSA) for a disability award letter and medical evidence of disability.
Reference:  For more information on determining the effective date of disability, see M21-, Part V, Subpart i, 2.2.d.

V.i.2.2.d.  Determining Disability Effective Date Based on Social Security Information

Unless VA pension eligibility is based on age, a Veteran must be disabled to be eligible. VA pension eligibility based on an SSA finding of disability should be effective from the later of
  • the date of receipt of the pension application, or
  • the date of disability.
The Social Security information available through Share may be used to determine eligibility for VA pension.
Social Security Benefit
Effective Date of Disability for Pension Purposes
SSI under Title XVI
  • If Share confirms payment of SSI, presume the Veteran was disabled from the date of receipt of the Pension application unless the DISABILITY ONSET DATE field shows more than one year after the date of receipt of the VA pension application.
  • If Share confirms payment of SSI, but the DISABILITY ONSET DATE field shows more than one year after the date of receipt of the Pension application, initially establish entitlement from the onset date and develop for an earlier effective date.
Note: SSA pays SSI from a date no earlier than the first month eligibility is established following receipt of the SSI application. Disability may exist for several months before the date SSI is paid.
Disability Insurance Benefits (DIB) under Title II
  • If the Veteran’s age is under 62, then presume the Veteran was disabled from the date in the DISABILITY ONSET DATE field.
    • If the date is on or before the first day of the month following the date of receipt of the VA pension application, establish eligibility from the date of claim.
    • If the date is later than the first day of the month following the date of receipt of the VA pension application, initially establish eligibility from the onset date and develop for an earlier effective date.
    • If the DISABILITY ONSET DATE field does not contain a date, develop to the Veteran and SSA for evidence of a disability and the effective date of disability.
  • If the Veteran’s age is 62, 63 or 64, then only presume the Veteran was disabled from the date in the DISABILITY ONSET DATE field when the date is exactly 6 full months before the DATE OF INITIAL ENT field. Otherwise, develop to the Veteran and SSA for evidence of a disability and the effective date of disability.
Reference:  For more information on when the evidence indicates payment of SSI, see M21-1, Part V, Subpart i, 2.2.c.

V.i.2.2.e.  When a Rating Determination of P&T Disability Is Required

If the Veteran is not age 65 or older, or presumed to be P&T disabled because he/she is a patient in a nursing home or VA approved medical foster home, or disabled as determined by the Commissioner of Social Security, then he/she must be shown by a rating to
  • meet the disability percentage requirements set forth in 38 CFR 4.16 and4.17 or have an extra-schedular evaluation approved under 38 CFR 3.321(b)(2), and
  • be unable to secure and follow a substantially gainful occupation (unemployable) by reason of disabilities which are likely to be permanent.

Note:  For pension claims that require a P&T disability determination, a general medical examination is necessary for all claims when there is insufficient medical evidence available to decide the claim.

References:  For more information on


V.i.2.2.f.  Acceptable Medical Evidence and Definition of Adequate Medical Evidence for Pension Rating Purposes 

Medical evidence is adequate for pension rating purposes as long as it addresses all medical or mental conditions provided by the Veteran and can be used to evaluate the impact of each condition on the Veteran’s employability.
The following types of medical evidence may be accepted for rating purposes if they are adequate:
  • a statement from a physician, Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS) or a Physician Assistant (PA), or
  • a hospital or examination report from any government or private institution.
Evidence of current disability may be contained in reports from a VA or a non-VA medical facility, or in evidence already of record showing the existence of a chronic condition likely to interfere with employability.  If such evidence is obtained, or is already of record, submit the claim to the rating activity.  If this evidence does not support a grant of P&T, and adequate medical evidence is not available, has not been provided, or is not of record, then a medical examination must be scheduled.

V.i.2.2.g.  VA Examination Authorization

Per 38 CFR 3.326(a), if the submitted medical evidence or medical evidence of record is not adequate for rating purposes, a VA examination will be authorized.
If the medical evidence …
And the medical evidence supports a …
Then …
is adequate for pension rating purposes
grant of pension benefits
grant pension by rating decision.  No VA examination is required.
is adequate for pension rating purposes
denial of pension benefits
deny pension by rating decision.  No VA examination is required.
does not address the conditions claimed by the Veteran
grant of pension benefits
grant pension by rating decision.  No VA examination is required.
is not adequate for pension rating purposes
denial of pension benefits
request a VA examination.
Note:  Claims processors have the authority to request an examination for any claim for which special circumstances may warrant it even if an examination is not required based on this topic.
Reference:  For the definition of adequate for pension rating purposes, see M21-1, Part V, Subpart i, 2.2.f.

V.i.2.2.hObtaining Evidence Before Referring a Claim to the Rating Activity

If no medical evidence of the claimed disability is of record, request medical evidence from the claimant.
If medical evidence is of record, but is not adequate for rating purposes, schedule the claimant for a VA examination.
Once adequate medical evidence is of record, refer the claim to the rating activity.
Note:  When questions of doubt arise in determining if medical evidence is adequate for rating purpose, refer claim to rating activity.
References:  For more information on

V.i.2.2.i.  Action to Take When Medical Evidence Is Not Received

If no medical evidence of the claimed disability has been received and 30 days have passed from the date of request
  • deny the claim
  • notify the Veteran that the evidence must be provided, and
  • notify the Veteran that in order for VA to review the evidence, the Veteran must file a supplemental claim.
No additional development is needed and no rating decision is completed.
Notes:
  • An examination may be needed, depending on the information provided on a lay statement. Follow the guidance outlined in 38 CFR 3.326(a) when ordering examinations when the medical evidence accompanying the claim is not adequate for rating purposes, where appropriate.
  • When questions of doubt arise involving having adequate medical information, refer the claim to the rating activity.
  • Do not immediately deny the claim if medical evidence necessary to decide the claim is located at a Federal facility.
References:  For more information on

V.i.2.2.j. Developing for Unemployability

In order for VA to make an unemployability decision, a Veteran must provide his/her work history for the one year period before he/she became disabled.
Use the table below to determine which form to send the Veteran when additional information is needed.
If …
Then send …
the employment information provided by a Veteran on an original claim is incomplete
VA Form 21-4138, Statement in Support of Claim, and ask him/her to provide the missing information on the form.
the Veteran is self-employed as a farmer
the Veteran is self-employed
  • the Veteran is not self-employed, and
  • additional evidence is required to determine the issue of unemployability or income
Note:  Only develop for additional evidence when the Veteran’s employment status is unclear.
  • for whom the Veteran has worked in the past 12 months, or
  • from whom he/she is receiving unemployment or retirement payments.
If the completed form is not received from the employer within 30 days, and the evidence is still relevant to the claim, inform the Veteran and ask him/her to obtain the completed form.
Note:  Use Modern Awards Processing-Development (MAP-D) for development whenever possible.
Reference:  For more information on development with MAP-D, see the MAP-D User’s Guide.

3.  Developing for Income and Net Worth


Change Date

April 21, 2015

V.i.2.3.a.  Requesting Necessary Evidence for Income and Net Worth

Do not develop in a piecemeal manner.  Develop for income information at the same time as for other evidence needed to determine entitlement.
Use the table below to find information on developing for various kinds of evidence.
For information on …
See …
developing for evidence of income and net worth
requesting information from sources such as the
  • Railroad Retirement Board
  • SSA, and
  • Office of Personnel Management

4.  Developing for the Willful Misconduct Aspect of an Injury


Introduction

This topic contains information on developing for the willful misconduct aspect of an injury, including

Change Date

April 21, 2015

V.i.2.4.a.  When to Develop for Willful Misconduct

Pension is not payable for any condition due to the Veteran’s own willful misconduct.
Develop the willful misconduct aspect of an injury in a pension case only when the residual disability from that injury would be a material factor in the grant or denial of a claim.  If there is doubt on this point, obtain advice from the rating activity.
Generally, if the facts of record are relatively clear as to the innocent incurrence of an injury, suggesting no element of willful misconduct, do not develop for this aspect of the claim.
Example:  Unless there is a reasonable probability of willful misconduct, the mere fact that the injury was incurred in an automobile accident is not sufficient reason to initiate development.
Reference:  For more information on willful misconduct, see

V.i.2.4.b.  Where to Find Information On  Administrative Determinations of Insanity
If there is a question as to whether a Veteran was insane at the time he/she committed an act that would otherwise be considered misconduct, see M21-1, Part III, Subpart v, 1.E.

5.  Referring Pension Claims to the Rating Activity


Introduction

This topic contains information on referring pension claims to the rating activity, including

Change Date

April 21, 2015

V.i.2.5.a.  General Information on Referring Pension Claims to the Rating Activity

Refer a claim to the rating activity, provided that
  • medical evidence adequate for rating has been received, or
  • evidence or allegations of record are sufficient to create a rating issue,and
  • the claimant meets all the criteria (service, income and net worth, and, for survivor claims, relationship).
References:  For information on

V.i.2.5.b.  Action to Take in Cases in Which the Veteran Does Not Meet the Minimum Service Requirement

If the Veteran does not meet the minimum service requirement, refer the claim to the rating activity for a determination of basic eligibility only if military service department records indicate that the Veteran was discharged because of disability.
References:  For information on
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