PTSD is caused by so many different events; personal trauma, sexual trauma, combat, reactions to training. It is the 6th highest rated disability among veterans, with over 63,000 new claims in 2015 and a total of over 800,000 veterans receiving compensation for symptoms of PTSD at some level. Many veterans are told they have PTSD and submit all the evidence required, but then when they apply for benefits they see this on their rating decision, “Does not meet the criteria for PTSD.” In this blog, we will explore various reasons why veterans get denied for this reason and what they can do about it.
Incorrect Rating Decisions:
Often the rating decision is just incorrect. Not that the veteran does not meet the PTSD criteria, but that they are denying a mental health disorder because the veteran filed for one disorder and actually has a different one.
Veterans, unless they have a doctorate in psychology, are not able to officially diagnose their own mental health disorders. Therefore, if a claim is filed for PTSD and it is denied because a veteran does not meet the criteria, the VA should have determined if the veteran had another diagnosis, which they often do not. Veterans can often avoid this process by filing a claim for a more generic issue such as “acquired psychiatric disorder” or “service connected mental health disorder.” By filing for benefits in this manner, it puts the responsibility on the VA to diagnose through a C&P exam and/or utilizing medical records where a diagnosis may already exist.
Understanding Criterion A of PTSD
This is one of the most puzzling aspects of diagnosing for lay people. Criteria A is what determines if a stressor can be used to support a diagnosis of PTSD. If there is no Criteria A, there is no diagnosis. However, many people, even doctors, often misunderstand the requirements for this diagnostic step. The criteria broken down are:
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- Directly experiencing the traumatic event(s);
- Witnessing, in person, the event(s) as it occurred to others;
- Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the events(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse.)
For many, the basic criteria listed above of 1 and 2 are easy to understand. Where we find mistakes most often are with criteria 3 and 4.
Criteria 3 states that the event must have happened to a family member or close friend. Often the VA will determine that members of a unit are not considered close friends if they have not served together for a certain period of time or were in a different geographical location. However, the culture of the military is one where even if unit members are on different continents, they are bound by a brotherhood and when members of a unit experience a trauma such as terrorism or a plane crash, the entire unit is affected; even support staff and support units, not just those who served directly together.
Criteria 4 is often mistaken for only being related to repeated events only such as those experienced by military security forces or convoy personnel. However, reading the criteria closer, it states, repeated or extreme. Extreme can mean a lot of things in the military world, terrorism, IEPDs, even having to write up the reports dealing with the death or losses of troops or civilians. And, extreme is about perception, what may be extreme may not be perceived as such by someone else, so discussing the events with a psychologist is important so that they can determine how the veteran perceived the event and if it meets Criteria A requirements for PTSD.
Understanding the General Rating Formula for Mental Health Conditions
Rating levels are determined by the General Rating Formula. This is where the VA takes the symptoms of any mental health condition and translates them into a rating of 10, 30, 50, 70, or 100%. The VA often rates veterans by the average of their symptoms, so if a veteran has symptoms that fall in the 30, 50, and 70% ranges, they will often get a 50% rating. However, this is not the correct way to rate a mental health disorder. Ratings should be based on the highest level of symptoms, not an average. So, if a veteran has 6 symptoms at 30%, 3 at 50% and 2 at 70%, they should be rated at 70%. Also, the VA cannot downplay symptoms and give them a lower rating. For example, if a veteran has suicidal ideations, that is a 70% rating. However, if the doctor states that the veteran does not have intent, the ideations are fleeting, and intermittent, the VA will sometimes reduce the rating or ignore the symptom all together and not rate it. However, it is never less than a 70% rating if a veteran has suicidal ideations, regardless of intent, plan, past hospitalizations, or if they are fleeting or constant.
If you are a veteran with a mental health rating, make sure you are getting the correct rating and the highest benefits you are entitled to, you deserve it for the price you paid to defend your country.