Section G - Benefits Under 38 U.S.C. 1151 - Updated 12/16/11

Chapter 2 - Rating

Overview


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In this Section
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33.   General Information on Entitlement to Benefits Under 38 U.S.C. 1151
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Introduction
This topic contains general information on entitlement to benefits under 38 U.S.C. 1151, including
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 ·      benefits under 38 U.S.C. 1151

 ·      a definition of hospital care under 38 U.S.C. 1151

 ·      qualifying disability or death under 38 U.S.C. 1151

 ·      determining whether additional disability exists

<span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      establishing fault on the part of VA

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the definitions of express consent and implied consent

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      establishing that an event was not reasonably foreseeable

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      entitlement to compensation under 38 U.S.C. 1151 vs. service connection

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering direct and presumptive service connection

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      obtaining independent medical evidence and medical opinions, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      disability or death resulting from treatment or care in a non-VA facility under VA contract. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">September 15, 2011 <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 33. General Information on Entitlement to Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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a.   Benefits Under 38 U.S.C. 1151
<p class="MsoBlockText">38 U.S.C. 1151 provides for the payment of compensation   for additional disability or death that is
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      not the result of the Veteran’s willful misconduct, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      attributable to

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     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)

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     participation in vocational rehabilitation training under 38 U.S.C. Chapter 31, or

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     participation in compensated work therapy (CWT).

<p class="MsoBlockText">

<p class="MsoBlockText">Award benefits for qualifying additional disability or death under 38 U.S.C. 1151 in the same manner as if the disability or death were service-connected (SC).

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Domiciliary care is not considered VA hospital care, medical or surgical treatment, or an examination for the purpose of establishing entitlement under 38 U.S.C. 1151 per Mangham v. Shinseki, 23 Vet.App. 284, 289 (2009).

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Per VAOPGCPREC 8-97, compensation may be paid for disability that is secondary to disability for which compensation is payable under 38 U.S.C. 1151.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on entitlement to compensation or DIC under the provisions of 38 U.S.C. 1151, see 38 CFR 3.361. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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b.   Definition:   Hospital Care Under 38 U.S.C. 1151
<p class="MsoBlockText">Hospital care under 38 U.S.C. 1151 includes the provision of services unique to the hospitalization of patients, according to Bartlett v. Shinseki, Vet.App., March 10, 2010.
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<p class="MsoBlockText">

<p class="MsoBlockText">Determining whether a situation involves hospital care depends on a variety of factors, including the

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      nature of services

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      degree of VA control over patient freedom

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      mental and physical condition of patients, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      foreseeability of potential harm.

<p class="MsoBlockText">

<p class="MsoBlockText">Example:

<p class="MsoBlockText">Situation

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="mso-bidi-font-size:12.0pt;font-family:Symbol;mso-fareast-font-family:  Symbol;mso-bidi-font-family:Symbol;color:windowtext"> ·      A Veteran was a patient in a lock-down psychiatric ward at a VA medical center (VAMC) when another psychiatric patient shoved him while standing in line at a cafeteria authorized for lock-down psychiatric patients.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="mso-bidi-font-size:12.0pt;font-family:Symbol;mso-fareast-font-family:  Symbol;mso-bidi-font-family:Symbol;color:windowtext"> ·      The Veteran

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     claimed he suffered back and neck injuries due to the altercation, and

<p class="BulletText2" style="mso-list:l0 level1 lfo3"><span style="mso-bidi-font-size:12.0pt;font-family:Symbol;mso-fareast-font-family:  Symbol;mso-bidi-font-family:Symbol"> -     stated he should be compensated under 38 U.S.C. 1151 because

<p class="BulletText3" style="mso-list:l2 level1 lfo2"> §   he was required to go to the cafeteria for meals, and

<p class="BulletText3" style="mso-list:l2 level1 lfo2"> §   two hospital staff members were required to escort the aggressor-patient, as VAMC personnel considered him to be dangerous.

<p class="MsoBlockText">

<p class="MsoBlockText">Result

<p class="BulletText1" style="margin-left:0in;text-indent:0in;mso-list:none;  tab-stops:.5in"> This situation involved hospital care under 38 U.S.C. 1151 because

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      VA staff

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     had total control of the Veteran’s movement in a lock-down psychiatric ward, and

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     mandated his presence at the cafeteria for meals, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the facility contained patients who were mentally unstable and dangerous in such a foreseeable way that VA staff provided escorts for them. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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c.   Qualifying Disability or Death Under 38 U.S.C. 1151
<p class="MsoBlockText">In order to meet the qualifications of 38 U.S.C. 1151, the proximate cause of additional disability or death must be
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      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

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an event not reasonably foreseeable, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the provision of

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     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, or

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     a CWT program.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      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.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      When determining whether a disability or death was the result of hospital care, and not merely coincident with the hospitalization, consider whether it was due to fault on the part of VA.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Eligibility based on participation in a CWT program is restricted to claims that were pending or received on or after November 1, 2000.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      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.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on proximate cause, see 38 CFR 3.361(d). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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d.   Determining Whether Additional Disability Exists
<p class="MsoBlockText">To determine whether a Veteran has incurred additional disability under 38 U.S.C. 1151, compare the Veteran’s condition immediately before the beginning of the VA medical care, training, or CWT program on which the claim is based to his/her condition afterwards.
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Each body part should be compared separately.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on determining whether a Veteran has incurred additional disability, see 38 CFR 3.361(b). <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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e.   Establishing Fault on the Part of VA
<p class="MsoBlockText">To establish that fault on the part of VA in furnishing medical care, treatment or examination was the proximate cause of a Veteran’s disability or death, the evidence must show that
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the medical care, treatment, or examination caused the additional disability or death, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      VA

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     failed to exercise the degree of care that would have been expected of a reasonable health-care provider, or

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     furnished the care without the Veteran’s or Veteran’s representative’s informed consent. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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f.   Definitions:   Express Consent and Implied Consent
<p class="MsoBlockText">Express consent is consent that has been clearly stated either orally or in writing.
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<p class="MsoBlockText">

<p class="MsoBlockText">Implied consent is consent that may be inferred from the circumstances in the case. Example:   If 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. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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g.   Establishing That an Event Was Not Reasonably Foreseeable
<p class="MsoBlockText">An event is considered “not reasonably foreseeable” if it is not the type of risk that would be disclosed as part of the informed consent procedures shown in 38 CFR 17.32.
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<p class="MsoBlockText">

<p class="MsoBlockText">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. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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h.   Entitlement to Compensation Under 38 U.S.C. 1151 vs. Service Connection
<p class="MsoBlockText">Although compensation or DIC is payable under 38 U.S.C. 1151 as if the additional disability or death were SC, the additional disability or death is not actually SC.
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<p class="MsoBlockText">

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i.   Considering Direct   and Presumptive Service Connection
<p class="MsoBlockText">Do not put direct service connection at issue if the only issue raised is compensation under 38 U.S.C. 1151, and the disability is clearly one that arose many years after service or coincident with treatment.
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<p class="MsoBlockText">

<p class="MsoBlockText">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. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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j.   Obtaining Independent Medical Evidence and Medical Opinions
<p class="MsoBlockText">To clarify whether the care, treatment, or examination at issue resulted in additional disability or death, it may be necessary to obtain
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a medical opinion from a VA medical facility as shown in M21-1MR, Part III, Subpart iv, 3.A.9

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      independent medical evidence, such as

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     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

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     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

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an independent medical opinion under 38 CFR 3.328, but only when warranted by the medical complexity or controversy involved in the case.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on obtaining independent medical opinions under 38 CFR 3.328, see M21-1MR, Part III, Subpart iv, 3.A.9.f through i. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 33. General Information on Entitlement to Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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k.   Disability or Death Resulting From Treatment or Care in a Non-VA Facility Under VA Contract
<p class="MsoBlockText">Hospital care, for the purposes of establishing entitlement to compensation under 38 U.S.C. 1151, does not include treatment or care provided in a non-VA facility under VA contract.
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<p class="MsoBlockText">

<p class="MsoBlockText">VA treatment or examination resulting in additional disability or death coincident with a Veteran’s residence in a contracted non-VA facility might result in eligibility under 38 U.S.C. 1151.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information, see 38 CFR 3.361(f). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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34.   Determining Entitlement to Benefits Under 38 U.S.C. 1151
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Introduction
<p class="MsoBlockText">This topic contains information on considering entitlement to benefits under 38 U.S.C. 1151, including considering compensation for disability resulting from
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an examination

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an act of omission

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a premature discharge

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      medication, and/or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      vocational rehabilitation training or in a CWT program, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Veteran’s failure to follow medical instructions. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">December 16, 2011 <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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a.   Considering Compensation for Disability Resulting From an Examination
<p class="MsoBlockText">38 U.S.C. 1151 authorizes compensation for disability resulting from a Veteran’s “having submitted to an examination” under any law administered by VA.
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<p class="MsoBlockText">

<p class="MsoBlockText">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.

<p class="MsoBlockText">

<p class="MsoBlockText">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.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on compensation for a disability resulting from VA examination, see Sweitzer v. Brown, 5 Vet.App. 503 (1993). <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 34. Determining Entitlement to Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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b.   Considering Compensation for Disability Resulting From an Act of Omission
<p class="MsoBlockText">Entitlement to compensation under 38 U.S.C. 1151 may be based on acts of omission as well as acts of commission.
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<p class="MsoBlockText">

<p class="MsoBlockText">A Veteran may be entitled to benefits under 38 U.S.C. 1151 if VA failed to perform one of the following actions:

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      timely diagnose or properly treat a disability, thereby causing increased disability or death, and/or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      obtain informed consent from the Veteran or the Veteran’s representative prior to treatment.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   The natural progression, that is, worsening, of a disease or injury may be the basis of eligibility under 38 U.S.C. 1151 only if it is attributable to VA’s failure to timely diagnose or properly treat the disease or injury.

<p class="MsoBlockText">

<p class="MsoBlockText">References:   For more information on

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      failure-to-diagnose claims under 38 U.S.C. 1151, see Roberson (C.) v. Shinseki, 607 F.3d 809-817 (2010)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      informed consent, see 38 CFR 17.32, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the natural progression of a disease or injury, see 38 CFR 3.361(c)(2). {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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c.   Considering Compensation for Disability Resulting From Premature Discharge
<p class="MsoBlockText">Compensation may be payable under 38 U.S.C. 1151 when a physician determines that a patient should be discharged from a hospital after a period of treatment, but the patient claims that the discharge
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      was too early, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      lead to a relapse and worsening of the disability.

<p class="MsoBlockText">

<p class="MsoBlockText">Consider whether the timing of the discharge aggravated the disability beyond the level of natural progression (that is, worsening).

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Development should include a request for a medical certificate indicating that the

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     Veteran’s condition at discharge was not stable, and

<p class="BulletText2" style="mso-list:l0 level1 lfo3"> -     discharge was premature.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      A medical opinion may be necessary in such a case. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 34. Determining Entitlement to Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Considering Compensation for Disability Resulting From Medication
<p class="MsoBlockText">Compensation is payable under 38 U.S.C. 1151 for any disability caused by medication that was prescribed by VA and taken or administered as prescribed, if the disability was directly due to
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      fault on the part of the VA, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an incident that could not have been reasonably foreseen.

<p class="MsoBlockText">

<p class="MsoBlockText">Example:   Compensation is payable under 38 U.S.C. 1151 if

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      VA prescribed a medication at ten times the proper dosage, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      additional permanent disability or death resulted from the erroneous prescription. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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e.   Considering Compensation for Disability Resulting From Vocational Rehabilitation Training or a CWT Program
<p class="MsoBlockText">Compensation may be payable under 38 U.S.C. 1151 for disability resulting from the Veteran’s participation in an essential activity or function of vocational rehabilitation training or a CWT program.
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<p class="MsoBlockText">

<p class="MsoBlockText">It need not be shown that VA approved the specific activity that resulted in disability, as long as the activity is considered a necessary component of the training or work therapy VA authorized.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information, see 38 CFR 3.361(d)(3). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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f.   Considering Compensation for Disability Resulting From Veteran’s Failure to Follow Medical Instructions
<p class="MsoBlockText">In some cases, the evidence will show that, following VA treatment or surgery, the Veteran
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      failed to follow post-treatment medical instructions, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      incurred or aggravated a disability that would not have developed had he/she followed instructions.

<p class="MsoBlockText">

<p class="MsoBlockText">In such cases, this failure may constitute an intercurrent cause, thereby precluding payment of benefits under 38 U.S.C. 1151. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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35.   Preparing a Rating Decision Involving a Claim for Benefits Under 38 U.S.C. 1151
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Introduction
<p class="MsoBlockText">This topic contains information on preparing a rating decision involving a claim for benefits under 38 U.S.C.1151, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      determining entitlement to benefits for an additional disability under 38 U.S.C. 1151

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      determining the additional degree of disability under 38 U.S.C. 1151

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      preparing the Reasons for Decision  in claims under  38 U.S.C. 1151

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      making uncorroborated conclusions in the rating decision

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      combining the disability ratings of qualifying disabilities under 38 U.S.C. 1151 and SC disabilities

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      possible eligibility for ancillary benefits based on qualifying disability under 38 U.S.C. 1151

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      ancillary benefits not available by reason of a qualifying disability under 38 U.S.C. 1151, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      obtaining an advisory opinion for claims under 38 U.S.C. 1151. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">September 15, 2011 {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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a.   Determining Entitlement to Benefits for Additional Disability Under 38 U.S.C. 1151
<p class="MsoBlockText">Establish entitlement to benefits for an additional disability under 38 U.S.C. 1151, if the evidence shows aggravation of a nonservice-connected (NSC), pre-existing condition as a result of
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      VA medical treatment or examination

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a course of vocational rehabilitation, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a CWT program. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 35. Preparing a Rating Decision Involving a Claim for Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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b.   Determining the Additional Degree of Disability for Claims Under 38 U.S.C. 1151
<p class="MsoBlockText">Follow the steps in the table below to determine the additional degree of disability for which benefits are payable under 38 U.S.C. 1151. <p class="MsoNormal"> <p class="MsoNormal"> {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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c.   Preparing the Reasons for Decision for the Claim Under 38 U.S.C. 1151
<p class="MsoBlockText">Provide an adequate discussion of the factual bases for the claim under 38 U.S.C. 1151 in the Reasons for Decision section of the rating decision. Indicate whatever surgery, treatment, or therapy was provided.
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<p class="MsoBlockText">

<p class="MsoBlockText">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. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 35. Preparing a Rating Decision Involving a Claim for Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Making Uncorroborated Conclusions in the Rating Decision
<p class="MsoBlockText">Do not make uncorroborated conclusions in the rating decision that a relationship between the treatment, surgery, or medication provided and the claimed disability does not exist.
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<p class="MsoBlockText">

<p class="MsoBlockText">Example:   Without corroborating medical evidence, a Rating Veterans Service Representative (RVSR) may not simply state that

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the evidence does not show a myelogram caused a claimant’s tinnitus, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      it is unlikely that the Veteran’s medications caused a claimed side effect.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For information on evaluating medical evidence for a rating decision, see M21-1MR, Part III, Subpart iv, 5.5. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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e.   Combining the Disability Ratings of Qualifying Disabilities Under 38 U.S.C. 1151 and SC Disabilities
<p class="MsoBlockText">Combine the disability rating(s) assigned to disabilities for which compensation is payable under 38 U.S.C. 1151 with the disability ratings assigned to SC disabilities, as if the former were service-connected.
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<p class="MsoBlockText">

<p class="MsoBlockText">If two or more disabilities (at least one being a qualifying disability under 38 U.S.C. 1151) 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 is acceptable.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   38 U.S.C. 1151 disabilities may serve as the basis of an individual unemployability (IU) award. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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f.   Possible Eligibility for Ancillary Benefits Based on Qualifying Disability Under 38 U.S.C. 1151
<p class="MsoBlockText">A Veteran with a qualifying disability under 38 U.S.C. 1151 may also be eligible for
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a clothing allowance

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      specially adapted housing benefits, including a special housing adaptation grant, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an automobile or adaptive equipment benefits.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference :    For more information on ancillary benefits, see

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part IX, Subpart i

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part III, Subpart iv, 6.B.3, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part IV, Subpart iii, 3.G.39.d. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 35. Preparing a Rating Decision Involving a Claim for Benefits Under 38 U.S.C. 1151, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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g.   Ancillary Benefits Not Available by Reason of a Qualifying Disability Under 38 U.S.C. 1151
<p class="MsoBlockText">The following ancillary benefits are not available by reason of a qualifying disability under 38 U.S.C. 1151:
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Service Disabled Veteran (RH) Insurance

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Civilian Health and Medical Program of VA (CHAMPVA)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      waiver of the loan guaranty funding fee

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 U.S.C. Chapter 31 education benefits

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 U.S.C. Chapter 35 education benefits

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the 10-point Civil Service Preference

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the special allowances under 38 U.S.C. 1312(a) and Public Law (PL) 87-377, Section 156, Restored Entitlement Program for Survivors (REPS)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      SC burial allowance, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      loan guaranty benefits for a surviving spouse. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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h.   Obtaining an Advisory Opinion for Claims Under 38 U.S.C. 1151
<p class="MsoBlockText">Submit unusually difficult cases involving claims for compensation under 38 U.S.C. 1151 to VA Central Office (CO) (211B) for an advisory opinion.
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<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on CO guidance and advisory opinions, see M21-1MR, Part III, Subpart vi, 1.
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