Veterans' Compensation: Evidence Considered in Persian Gulf War
Undiagnosed Illness Claims (Letter Report, 05/28/96, GAO/HEHS-96-112).

Pursuant to a congressional request, GAO reviewed the procedures the
Department of Veterans Affairs (VA) uses to process Persian Gulf War
undiagnosed illness claims.

GAO found that: (1) before VA will provide benefits, veterans must
provide it with evidence of a chronic disability and verifiable evidence
of time lost from work, prior medical treatment, or changes in
appearance, physical abilities, or psychological condition; (2) both
denied and approved claims consist primarily of service medical records
and VA medical examinations, but approved claims usually include an
independent medical history and sometimes include nonmedical evidence;
(3) denied claims lacked sufficient evidence because of poor VA
procedures and veterans' failure to collect relevant information; and
(4) while VA reports that most denied claims were denied because the
alleged disability did not become evident during active duty or the
subsequent 2-year presumptive period, it stated in denial letters to
veterans that their claims lacked sufficient evidence.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-112
     TITLE:  Veterans' Compensation: Evidence Considered in Persian Gulf 
             War Undiagnosed Illness Claims
      DATE:  05/28/96
   SUBJECT:  Veterans
             Veterans benefits
             Veterans disability compensation
             Military benefits claims
             Claims processing
             Medical examinations
             Data collection operations
             Medical records
             Claims settlement
IDENTIFIER:  Persian Gulf War
             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Committee on Veterans'
Affairs, U.S.  Senate

May 1996

VETERANS' COMPENSATION - EVIDENCE
CONSIDERED IN PERSIAN GULF WAR
UNDIAGNOSED ILLNESS CLAIMS

GAO/HEHS-96-112

Persian Gulf Undiagnosed Illness Claims

(107543)


Abbreviations
=============================================================== ABBREV

  VA - Department of Veterans Affairs
  VARO - Department of Veterans Affairs Regional Office

Letter
=============================================================== LETTER


B-265991

May 28, 1996

The Honorable John D.  Rockefeller IV
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate

Dear Senator Rockefeller: 

Over 700,000 men and women served in Southwest Asia during the
Persian Gulf War.  Some of these veterans began experiencing
symptoms--such as fatigue, weight loss, and skin conditions--that
could not be diagnosed or associated with a specific illness or
disease.  In 1994, the Congress enacted legislation allowing the
Department of Veterans Affairs (VA) to pay compensation benefits to
veterans for Persian Gulf related disabilities caused by undiagnosed
illnesses.  As of July 1995, VA had denied almost 95 percent of the
4,144 claims it had processed for Persian Gulf veterans claiming such
disabilities. 

Concerned about the high denial rate, you asked us to identify the
procedures that VA used to process Persian Gulf War undiagnosed
illness claims.  In this report, we identify (1) the evidence
standards that VA has established to process Persian Gulf claims, (2)
the evidence in the claim files that VA considered in reaching its
decisions, and (3) VA's reporting of the reasons for denial. 

To accomplish our objectives we conducted discussions with officials
of VA's central office and its four area processing offices that
process Persian Gulf claims and we obtained and analyzed pertinent
documents and records, such as VA's regulation and procedures for
processing Persian Gulf claims.  We also analyzed a nationally
representative sample of the undiagnosed illness claims that VA had
denied as of September 1995 and for purposes of comparison, we
reviewed a random, nonstatistical sample of granted claims.  Further
details of our scope and methodology are in appendix I. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Before compensation can be paid for an undiagnosed illness, VA
requires evidence that a chronic disability developed within 2 years
of a veteran's service in the Persian Gulf War.  Such evidence could
include support from an examining physician and nonmedical evidence
that can be independently verified, such as lost time at work or
statements from individuals familiar with the veteran's condition. 

For the denied undiagnosed illness claims that we reviewed, the
evidence included mainly service medical records and VA medical
exams.  Few of the files contained nonmedical evidence.  For the
granted claims, the evidence was similar but, in general, showed a
history of treatment for the claimed condition.  For the most part,
VA denied the claims for a lack of evidence.  Both VA and the
veterans may have contributed to this lack of evidence.  In some
instances, VA did not provide required assistance or clear and useful
information to veterans regarding the type of evidence needed to
support undiagnosed illness claims.  On the other hand, even when VA
followed appropriate procedures to develop the claims, veterans did
not always provide the evidence needed to support their claims. 
Although VA has rarely granted compensation for undiagnosed
illnesses, many Gulf War veterans have received VA benefits for
diagnosable service-connected conditions that accompanied their
undiagnosed illness claims.  Of the denied claims that we reviewed,
60 percent of the veterans had been granted compensation for
diagnosable illnesses. 

VA's reports to the Congress regarding undiagnosed illness claims
have not always accurately described the reasons that claims were
denied.  In most of the denied cases that we reviewed, VA found
insufficient evidence to support the claimed disability but reported
that the claims were denied because the disability did not arise
during the 2-year presumptive period.  These VA reports suggest that
veterans had well-documented disabling conditions but would receive
no compensation simply because their disability arose at some time
outside of the presumptive period.  Our work suggests that in most
cases, even with an extended presumptive period, more evidence would
have been needed before VA could grant compensation.  VA plans to
assess the extent of the problem and take the necessary corrective
action. 


   BACKGROUND
------------------------------------------------------------ Letter :2

As has been reported by many researchers, some Gulf War veterans
developed illnesses that could not be diagnosed or defined and for
which other causes could not be specifically identified.  These
illnesses have been attributed to many sources, including a large
number of unusual environmental hazards found in the Gulf.  The
Congress enacted the Persian Gulf War Veterans' Benefits Act\1 (P.L. 
103-446, Nov.  2, 1994) which, among other things, allowed VA to pay
disability compensation to veterans suffering from undiagnosed
illnesses attributed to their service in the Persian Gulf. 
Compensable conditions include but are not limited to abnormal weight
loss, cardiovascular symptoms, fatigue, gastrointestinal symptoms,
headaches, joint and muscle pains, menstrual disorders, neurologic
symptoms, neuropsychological symptoms, skin disorders, respiratory
disorders, and sleep disturbances. 

Under the procedures that VA established to process undiagnosed
illness claims, veterans submit completed claim forms to a VA
regional office (VARO).  Each VARO is responsible for fully
developing the claims.  VAROs obtain medical records from the
military services; arrange for a VA medical examination; and obtain
evidence from other sources, such as private health care providers or
knowledgeable lay persons, if the veteran identifies such sources. 
Once the claim is developed, the claims file is transferred to one of
the four area processing offices that VA has designated for
processing undiagnosed illness claims. 

As mentioned earlier, over 700,000 men and women served in the
Persian Gulf War.  VA reported that as of February 1996, it has
processed 7,845 undiagnosed illness claims and has identified an
additional 6,655 claims that are being evaluated for undiagnosed
illnesses.\2 Of the processed claims, VA had denied compensation for
undiagnosed illness to 7,424 veterans--a denial rate of 95 percent. 


--------------------
\1 Title I of the Veterans' Benefits Improvements Act of 1994. 

\2 VA reviews all Persian Gulf compensation claims that are based on
exposure to environmental hazards to determine if benefits could be
granted for undiagnosed illness whether or not the veteran claims
such an illness. 


   VA PROCEDURES REQUIRE VETERANS
   TO PROVIDE EVIDENCE PROVING
   THEIR CLAIMS
------------------------------------------------------------ Letter :3

In February 1995, VA issued a regulation (38 C.F.R.  3.317) that
specifies the evidence required before compensation can be paid for
an undiagnosed illness claim.  Under the regulation, veterans must
provide objective indications of a chronic disability.  Objective
indications include both signs--evidence perceptible to the examining
physician--and other nonmedical indications that are capable of
independent verification.  In the final rule, VA explained that
nonmedical indicators of a disabling illness include but are not
limited to such circumstances or events as (1) time lost from work;
(2) evidence that a veteran has sought medical treatment for his or
her symptoms; and (3) evidence affirming changes in the veteran's
appearance, physical abilities, or mental or emotional attitude.  The
evidence requirements contained in the regulation are consistent with
the Joint Explanatory Statement that accompanied the Veterans'
Benefits Improvements Act of 1994. 

According to the VA regulation, a veteran can only be compensated for
disabilities caused by undiagnosed illnesses that (1) manifest
themselves during service in the Gulf War or (2) arise within 2 years
of a veteran's departure from the Persian Gulf.  If the illness arose
after the veteran left the Gulf, the veteran must be at least
10-percent disabled to be compensated.  In addition, the veteran must
demonstrate that the disabling condition is chronic--present for 6
months or longer. 

In some cases, lay statements can provide critical support for a
veteran's undiagnosed illness claim.  As stated in the VA claims
processing manual, lay statements may be especially important in
cases where an undiagnosed illness is manifest solely by symptoms
that the veteran reports and that would, therefore, not be subject to
verification through medical examination.  Examples of such symptoms
include headaches and fatigue.  According to VA, lay statements from
individuals who establish that they are able from personal experience
to make their observations or statements will be considered as
evidence if they support the conclusion that a disability exists. 

While veterans are ultimately responsible for proving their claims,
VA is required by statute to assist the veteran in developing facts
to prove the claim.  The U.S.  Court of Veterans' Appeals has also
held in its decisions that VA has a duty to assist veterans with
proving their claims and is required to obtain relevant facts from
sources identified by claimants.  A VA letter dated February 15,
1995, instructed all VA regional offices that "if a veteran alleges
that a disability began after military service, request objective
evidence (lay or medical) to establish that fact."


   EXPERIENCE IN REVIEWING CLAIMS
   EVIDENCE
------------------------------------------------------------ Letter :4

Many types of evidence can be used to support undiagnosed illness
claims.  The denied claims that we reviewed contained primarily
service medical records and VA medical examinations.  About 15
percent of the claims included medical records from private
physicians seen by the veterans after leaving military service and
less than 3 percent contained nonmedical evidence related to an
undiagnosed illness, such as lay statements and records showing lost
time from work. 

The granted claims that we reviewed also contained primarily service
medical records and VA examinations.  In these cases, however,
veterans were usually able to provide VA with a history, after
leaving the Persian Gulf, of treatment for the granted undiagnosed
condition.  Some granted claims were supported with nonmedical
evidence, such as a sworn statement from an individual with knowledge
of the veteran's disability.\3

Many of the veterans evaluated for undiagnosed illnesses are also
examined for other diagnosable service-connected illnesses and
injuries.  While VA does not often grant compensation for undiagnosed
conditions, these veterans often receive compensation for diagnosable
injuries or illnesses.  Of the cases that we reviewed where the
claimed undiagnosed illness(es) had been denied, about 60 percent of
the veterans had been granted compensation for at least one
service-connected diagnosable condition, such as hypertension,
hearing loss, or knee disorders.  About one-half of these veterans
were granted a disability payment; the remainder, with minor
impairments, are eligible for free care for their conditions through
the VA medical system. 


--------------------
\3 About one-half of the undiagnosed conditions that VA granted were
found to be 10-percent disabling, with the highest disability rating
being 40 percent. 


      VA DID NOT ALWAYS PROVIDE
      REQUIRED ASSISTANCE OR CLEAR
      AND USEFUL INFORMATION
---------------------------------------------------------- Letter :4.1

The lack of evidence to support undiagnosed illness claims may in
part be the result of poor VA procedures to elicit such information,
as the following examples indicate. 

  -- In late 1995, VA's central office conducted a review of 203
     completed undiagnosed illness claims.  VA found that additional
     specialty examinations should have been ordered in 23 cases
     (about 11 percent).  At the time of our work, VA stated that the
     required examinations would be scheduled and the veterans' cases
     would be reconsidered based on the additional evidence. 

  -- In 5 of the 79 denied cases that we reviewed, VA had not
     requested records from physicians who had treated the veteran
     since leaving military service.  For one case, VA officials
     stated that an attempt was made to obtain the evidence but the
     doctor failed to respond.  In three cases officials stated that
     the medical records were not obtained due to error.  According
     to area processing office officials, private medical records
     were not obtained in the other case because the veteran visited
     the doctor after the presumptive period. 

  -- Although VA recognizes the importance of nonmedical objective
     evidence--for example, work records and lay statements from
     knowledgeable individuals--in supporting some undiagnosed
     illness claims, VA's standard compensation claim form does not
     request such evidence.  The form does ask veterans to identify
     individuals who know about the veteran's medical treatment while
     in the service; in many cases, however, the claimed undiagnosed
     illness was not treated in the service.  According to VA
     officials, the form was designed to obtain evidence about
     typical illnesses and injuries that usually occur while veterans
     are in the service as opposed to Persian Gulf illnesses that can
     become manifest after veterans leave military service. 

  -- While the VA form does not specifically request nonmedical
     information, about 15 percent of the veterans did provide VA
     with the names of individuals who were knowledgeable about their
     claimed illness.  However, VA did not obtain statements from
     these individuals. 

Officials at the area processing offices cited several reasons why
lay statements were not obtained or used.  These reasons include the
veteran's failure to provide a complete address for the knowledgeable
individual and that the evidence fell outside the presumptive period. 
In one case, an area processing office official stated that VA should
have obtained the statements.  While the head of the claims
processing unit at one area processing office questioned the value of
lay statements and whether VA was responsible for obtaining them, VA
central office officials acknowledged that VA was responsible for
obtaining lay statements and a central office official told us that
statements would be obtained for the cases that we identified and
that the claims would be reconsidered after the statements were
obtained. 

  -- After the Congress passed legislation allowing compensation for
     undiagnosed illnesses, VA reexamined all completed Gulf War
     claim files to determine if compensation was warranted.  In some
     of these cases that we reviewed, there was no indication that VA
     had informed the veteran after the legislation about the
     specific types of medical and nonmedical evidence that could be
     submitted to support the claim.  According to VA officials, VA
     had decided to provide this information to the veterans on a
     case-by-case basis. 

VA's central office acknowledged that the existing procedures to
develop undiagnosed illness claims are not adequate and that area
processing offices could do a better job of requesting both medical
and nonmedical evidence from veterans in support of undiagnosed
illness claims.  VA has taken a step to provide better information to
veterans regarding evidence to support undiagnosed illness claims. 
VA has developed a letter that clearly states the types of medical
and nonmedical evidence that can be used to support these claims.  VA
is now sending this letter to all veterans who file undiagnosed
illness claims. 


      VETERANS DID NOT ALWAYS
      PROVIDE NEEDED SUPPORT FOR
      CLAIMS
---------------------------------------------------------- Letter :4.2

In the denied cases that we reviewed, even when VA followed all
appropriate procedures to develop claims, the veterans did not always
provide the necessary evidence that would allow their claims to be
granted. 

  -- Only 30 percent of the veterans in the denied cases that we
     reviewed provided evidence that they had sought medical
     treatment for the claimed undiagnosed condition after leaving
     the service--some veterans said that they could not afford
     medical treatment from private providers while others indicated
     that they were too busy to see a physician. 

  -- About 40 percent of the veterans in the denied cases that we
     reviewed were informed that their denied undiagnosed illness
     claims would be reconsidered if additional evidence was
     submitted; and VA thoroughly described the evidence that would
     be acceptable.  However, only 4 percent of these cases included
     any additional information from the veteran. 

  -- Twenty-three percent of the veterans in the denied cases that we
     reviewed did not show up for all the scheduled examinations.  As
     a result, VA was unable to identify and thoroughly evaluate the
     claimed disabling conditions. 


   VA REPORTS OVERSTATE
   PRESUMPTIVE PERIOD AS REASON
   FOR DENIAL
------------------------------------------------------------ Letter :5

VA does not always correctly categorize the reason undiagnosed
illness claims were denied.  VA requires each of its area processing
offices to record the reason that undiagnosed illness claims were
denied.  Reported results are compiled and presented periodically to
the Congress.  According to VA, most claims are denied because the
claimed disability did not become manifest on active duty in the
Persian Gulf or during the 2-year presumptive period.  Table 1 shows
the latest data submitted by VA. 



                                Table 1
                
                  Reasons VA Denied 7,424 Persian Gulf
                    Undiagnosed Illness Claims as of
                             February 1996

                                                                Percen
Reason for denial                                       Number       t
------------------------------------------------------  ------  ------
Illness diagnosed                                          685    9.23
Illness not chronic                                        177    2.38
Due to other cause                                          29    0.39
Not manifest during service in the Gulf or during the    4,640   62.50
 2-year presumptive period
Not shown by evidence                                    1,776   23.92
Less than 10-percent disabling                             117    1.58
----------------------------------------------------------------------
Of the denied claims that we reviewed, most--68 percent--had been
categorized by VA as being denied because the claimed illness did not
become manifest on active duty or during the presumptive period. 
However, in most of these cases, VA had explained in its decision
letter to the veteran that insufficient evidence was presented to
demonstrate that the claimed conditions existed, was chronic, or was
disabling to a compensable degree of 10 percent or more. 

By failing to appropriately categorize denied claims, VA may be
creating the impression that many veterans with otherwise compensable
disabilities do not receive benefits solely as a result of the
presumptive period.  Our review suggests that if the presumptive
period was extended, VA would still be required to deny the claims
unless the veteran provided additional evidence regarding the chronic
nature or disabling impact of the illness.  VA officials acknowledged
that their current reports could be misinterpreted.  They told us
that VA will assess the extent of the problem and take the necessary
corrective action. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :6

We obtained comments on a draft of this report from VA officials,
including the Deputy Under Secretary for Benefits.  The officials
generally agreed with our findings and noted that the agency is
taking additional steps to address the concerns that we raised. 
Specifically, VA officials reiterated their commitment to providing
veterans with better information regarding acceptable evidence to
support undiagnosed illness claims and to more accurately categorize
the reasons that claims are denied.  The officials told us that VA's
central office will also undertake additional claims reviews to
ensure that field offices are following all appropriate procedures. 
VA's comments included some technical changes, primarily for
clarification, which we incorporated in this report as appropriate. 

As arranged with your office, unless you announce its contents
earlier, we plan no further distribution of this report until 7 days
after the date of this letter.  At that time, we will send copies to
the Chairman, Senate Committee on Veterans' Affairs; the Secretary of
Veterans Affairs; and other interested parties. 

This work was performed under the direction of Irene Chu, Assistant
Director, Health Care Delivery and Quality Issues.  If you or your
staff have any questions, please contact Ms.  Chu or me on (202)
512-7101.  Other major contributors to this report are listed in
appendix II. 

Sincerely yours,

David P.  Baine
Director, Health Care Delivery
 and Quality Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To identify the evidence standards that VA established to process
Persian Gulf War claims, we visited the VA central office in
Washington, D.C., and two of the four area processing offices that VA
designated as responsible for processing undiagnosed illness
claims--Louisville, Kentucky, and Nashville, Tennessee (which
together processed 72 percent of undiagnosed illness claims).  We
also conducted telephone discussions with officials at the other two
area processing offices--Phoenix, Arizona, and Philadelphia,
Pennsylvania.  We also obtained pertinent documents and records from
these offices. 

To obtain information about the undiagnosed illness disability
compensation claims, we statistically sampled 79 of the 4,990 claims
that VA had denied as of September 21, 1995.  We randomly selected
the claims from VA's database of completed Persian Gulf War claims. 
Our sample size provides a 90-percent confidence level that the
characteristics of our sample match the total population of denied
claims within a specified error rate.  The error rate was no greater
than 11 percent. 

We also reviewed the claims files of 26 randomly selected veterans
from the 273 whose claims for undiagnosed illnesses had been granted
as of September 21, 1995.  We selected four granted claims each from
the Nashville, Louisville, and Philadelphia offices and 14 from the
Phoenix office.  We selected additional claims from the Phoenix
office because it had processed 32 percent of all granted claims
although it only processed 11 percent of all Persian Gulf claims. 
This was not a statistical sample; therefore, the results cannot be
projected to the universe of granted claims.  Instead, we reviewed
these claims to allow a comparison with the denied claims. 

In conducting our samples we reviewed documents pertinent to our
work, including the veterans' application forms; letters from VA to
the veterans about additional evidence; medical examinations; and
rating statements with the letters containing VA's decisions.  Data
about all Persian Gulf War illnesses and other information were
abstracted from those documents and entered into a database for
analysis. 

The purpose of our review of the denied and granted claim files was
to identify the evidence contained therein and gain additional
information on VA's reasons and bases for denying or granting the
claims.  We made no effort to assess the appropriateness of VA's
decisions.  We performed our review between August 1995 and March
1996 in accordance with generally accepted government auditing
standards. 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix II

Richard Wade, Evaluator-in-Charge
Jon Chasson, Senior Evaluator
Robert DeRoy, Assistant Director, Data Analysis and Evaluation
Support
Cynthia Forbes, Senior Evaluator
Michael O'Dell, Senior Social Science Analyst
Susan Poling, Assistant General Counsel
Pamela A.  Scott, Communications Analyst


*** End of document. ***