38 CFR 3.304 - Direct service connection; wartime and peacetime.
§ 3.304 Direct service connection; wartime and peacetime.
(a) General. The basic considerations relating to service connection are stated in § 3.303. The criteria in this section apply only to disabilities which may have resulted from service in a period of war or service rendered on or after January 1, 1947.
(b) Presumption of soundness. The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted.
(Authority: 38 U.S.C. 1111)
(1) History of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. Determinations should not be based on medical judgment alone as distinguished from accepted medical principles, or on history alone without regard to clinical factors pertinent to the basic character, origin and development of such injury or disease. They should be based on thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or disease or residuals thereof.
(2) History conforming to accepted medical principles should be given due consideration, in conjunction with basic clinical data, and be accorded probative value consistent with accepted medical and evidentiary principles in relation to value consistent with accepted medical evidence relating to incurrence, symptoms and course of the injury or disease, including official and other records made prior to, during or subsequent to service, together with all other lay and medical evidence concerning the inception, development and manifestations of the particular condition will be taken into full account.
(3) Signed statements of veterans relating to the origin, or incurrence of any disease or injury made in service if against his or her own interest is of no force and effect if other data do not establish the fact. Other evidence will be considered as though such statement were not of record.
(Authority: 10 U.S.C. 1219)
(c) Development. The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination. In initially rating disability of record at the time of discharge, the records of the service department, including the reports of examination at enlistment and the clinical records during service, will ordinarily suffice. Rating of combat injuries or other conditions which obviously had their inception in service may be accomplished pending receipt of copy of the examination at enlistment and all other service records.
(d) Combat. Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation.
(Authority: 38 U.S.C. 1154(b))
(e) Prisoners of war. Where disability compensation is claimed by a former prisoner of war, omission of history or findings from clinical records made upon repatriation is not determinative of service connection, particularly if evidence of comrades in support of the incurrence of the disability during confinement is available. Special attention will be given to any disability first reported after discharge, especially if poorly defined and not obviously of intercurrent origin. The circumstances attendant upon the individualveteran's confinement and the duration thereof will be associated with pertinent medical principles in determining whether disability manifested subsequent to service is etiologically related to the prisoner of war experience.
(f) Posttraumatic stress disorder. Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. The following provisions apply to claims for service connection of posttraumatic stress disorder diagnosed during service or based on the specified type of claimed stressor:
(1) If the evidence establishes a diagnosis of posttraumatic stress disorder during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor.
(2) If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor.
(3) If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, “fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and theveteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.
(4) If the evidence establishes that the veteran was a prisoner-of-war under the provisions of § 3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor.
(5) If a posttraumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate theveteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a posttraumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred.

Secondary Conditions

38 CFR 3.303 - Principles relating to service connection.

(a) General. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the Department of Veterans Affairs to administer the law under a broad and liberal interpretation consistent with the facts in each individual case.
(b) Chronicity and continuity. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim.
(c) Preservice disabilities noted in service. There are medical principles so universally recognized as to constitute fact (clear and unmistakable proof), and when in accordance with these principles existence of a disability prior to service is established, no additional or confirmatory evidence is necessary. Consequently with notation or discovery during service of such residual conditions (scars; fibrosis of the lungs; atrophies following disease of the central or peripheral nervous system; healed fractures; absent, displaced or resected parts of organs; supernumerary parts; congenital malformations or hemorrhoidal tags or tabs, etc.) with no evidence of the pertinent antecedent active disease or injury during service the conclusion must be that they preexisted service. Similarly, manifestation of lesions or symptoms of chronic disease from date of enlistment, or so close thereto that the disease could not have originated in so short a period will establish preservice existence thereof. Conditions of an infectious nature are to be considered with regard to the circumstances of the infection and if manifested in less than the respective incubation periods after reporting for duty, they will be held to have preexisted service. In the field of mental disorders, personality disorders which are characterized by developmental defects or pathological trends in the personality structure manifested by a lifelong pattern of action or behavior, chronic psychoneurosis of long duration or other psychiatric symptomatology shown to have existed prior to service with the same manifestations during service, which were the basis of the service diagnosis, will be accepted as showing preservice origin. Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation.
(d) Postservice initial diagnosis of disease. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and Department of Veterans Affairs regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid.

Veterans Legal Aid

Other examples that may be secondary are:
If you have a rated hip condition and it affects your back, you may want to file for the back pain as a secondary

condition. If you take medications for service connected PTSD, you may be eligible to file for erectile dysfunction.

Many psychiatric medicines will cause or contribute to ED. If you are rated (service connected) for hearing loss,

don't overlook the tinnitus that may accompany acoustic trauma. Severe hearing loss may also lead to mental health

conditions like depression. If you have a condition that has caused significant disability to a leg, that injury

may affect the other leg, the hip or your back.

The VA will almost certainly deny your claim for a secondary condition. That's why we have expert doctors for IMOs and

veterans law attorneys to manage appeals. Appeal is just a part of the process...go for it.

You should  consider obtaining an IME/IMO  at your earliest convenience.

​​Diabetes (DMII) as a primary condition

Diabetes is known to be very hard on the human vascular system. The veteran who has
diabetes will be monitored for diseases of the arteries of the heart, the neck, the kidneys and the legs. If diabetes affects those arteries the veteran may develop ischemic heart disease, carotid artery disease, renal artery disease or peripheral artery disease.Those diagnoses may lead to heart attack, stroke, kidney failure and difficulty in walking or even loss of a leg. If there is a diagnosis of DMI and that diagnosis is rated by VA as service connected, vascular diseases that are diagnosed later will be viewed as secondary conditions and will deserve an award of compensation. Interestingly, the diagnosis of service connected DMII must come first. If a veteran claims carotid artery disease in 2006 and is denied and then in 2009 he is diagnosed as having service connected DMII, the original denial is likely to remain as is. For a claim of a secondary condition, the primary service connected condition must be of record first. If the veteran has service connected diabetes, he or she may consider filing for;

Peripheral Artery Disease 
Ischemic Heart Disease 
Carotid Artery Disease 
Kidney Disease 
Diseases of the Eye 

There are many more conditions that may be caused by service connected diabetes.

​In our example of DMII, not all other conditions can be successfully claimed. This is a common error made by many veterans.Veterans who have a service connected condition like DMII will often begin to try to claim all other conditions as secondary to that DMII. 

We receive frequent emails asking if we think that a claim of arthritis,  mental conditions like  depression, various cancers and so on can be claimed as secondary to  the DMII. The answer is always "No". Veterans are allowed to make any  claim they believe is appropriate. Our answers are based on whether or  not we believe the veteran will be awarded the benefit or if he is  wasting his time. Many claims of a secondary condition may be won with an  expert Independent Medical Opinion.

Secondary Conditions are disabling injuries, illnesses or diseases that may be caused or aggravated by your existing service connected conditions. Nomenclature is very important when working with VA so it helps for you to understand  the language.

The term "condition" is used to describe any physical or mental health problem you may have.  A condition is an injury or an illness that occurred during your military service. The condition may be disabling or not.  You may have had a condition like a fungal infection that was treated and cleared up with treatment. That isn't disabling but it may be rated as service connected at 0% disabling. Or you may have had a significant injury such as a gunshot wound. Even though it was treated, that wound may have left you with only a

partial use of the affected limb and a big scar. That's a disabling condition and will likely be awarded an appropriate rating for purposes of compensation.

The term "service connected" implies that the illness or injury occurred during your service or if it shows up later in your life, was caused, contributed to or aggravated by your service.The condition doesn't have to be from combat or even while you're performing a

military duty. You're military 24 x 7 so anything that happens before you have that DD 214 in hand counts. These conditions can be physical illnesses or mental health problems. Some service connected conditions are pretty easy to understand. If you lose a finger or a  toe in an accident or in combat, you'll get a clear cut rating for the loss of the digit. That loss isn't pleasant but it isn't very likely to disrupt your life to any great extent and it won't lead to any other physical problems for you. Then again, you may be diagnosed with an illness or incur an injury that can cause other problems. If you have a service connected condition and that condition leads to other physically or mentally disabling conditions, you may have a reason to file a claim for a secondary condition.

Veterans who served in Vietnam are known to have been exposed to agent orange.  

Agent orange is known to cause or contribute to a variety of health problems. Your VA cedes that many health problems that occur in Vietnam veterans may be caused by the exposure to agent orange. In fact, there's a well defined list of these presumptive conditions.One of the common conditions that may be seen in the Vietnam veteran is adult onset diabetes, often called Type 2 Diabetes or DMII. Any Vietnam veteran who receives a diagnosis of DMII should file a claim for disability compensation. The claim is likely to be awarded without too much fuss if the veteran has his paperwork in proper order. Once an individual is diagnosed

with DMII his health care team will begin to watch for  conditions that are known to be secondary to the diabetes. Medical science recognizes that diabetes can be a brutal disease and it may cause other physical health problems. Many of these problems may be avoided or minimized with good medical care like a proper diet and medicines. Some manifestations of DMII will come up for some veterans though. These may be viewed as secondary conditions and when they occur, they should be claimed as service connected and secondary to the primary DMII.​

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​§3.310  Disabilities that are proximately due to, or aggravated by, service-connected disease or injury.

(a) General. Except as provided in §3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.

§4.22  Rating of disabilities aggravated by active service.
In cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree existing at the time of entrance into the active service whether the particular condition was noted at the time of entrance into the active service, or it is determined upon the evidence of record to have existed at that time. It is necessary therefore, in all cases of this character to deduct from the present degree of disability the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule, except that if the disability is total (100 percent) no deduction will be made. The resulting difference will be recorded on the rating sheet. If the degree of disability at the time of entrance into the service is not ascertainable in terms of the schedule, no deduction will be made.

Hearing Loss and Tinnitus Bringing You Down???

Are you depressed, anxious, angry or moody because of your hearing problems?
Did you know your mental health issues may be secondary to hearing loss or tinnitus?
Dr. Brett Valette is a clinical psychologist specializing in veterans mental health disability. If you're suffering with problems you believe may be caused or aggravated by hearing loss,
contact Dr. Valette and ask if you may have a secondary service connected condition.

BVA Decisions

Board of Veterans Appeals decisions are required reading for the veteran involved in a claim or an appeal.  You should recognize that BVA decisions do not  establish precedent. In legal systems based on common law, a precedent, or authority, is a principle or rule

established in a previous legal case that is either binding on or persuasive for a court or other tribunal when deciding subsequent cases with similar issues or facts. At VA and BVA every case is decided on its own merit. When you find a case similar to yours, you'll want to read it through and learn what that veteran did to win his appeal or if the case was denied, why? If you pattern your case in a way similar to those with positive outcomes, you're likely to prevail.

BVA Decision
THE ISSUES1. Entitlement to service connection for bowel incontinence, to include as secondary to service-connected lumbar disc disease. 2. Entitlement to service connection for bladder incontinence, to include as secondary to service-connected lumbar disc disease. 3. Entitlement to service connection or numbness and tingling of the right upper extremity, to include as secondary to service-connected lumbar disc disease. 4. Entitlement to service connection for numbness and tingling of the left upper extremity, to include as secondary to service-connected lumbar disc disease.

BVA Decision
THE ISSUES 1. Entitlement to service connection for degenerative joint disease, left hip,

secondary to service-connected left hallux valgus, left great toe, status post-bunionectomy and metatarsal osteotomy.  2. Entitlement to service connection for left lower extremity sciatica secondary to service-connected degenerative arthritis of the lumbar spine at L3-L4, L5-L6, and L6-S1. 3. Entitlement to service connection for right lower extremity sciatica secondary to service-connected degenerative arthritis of the lumbar spine at L3-L4, L5-L6, and L6-S1. 4. Entitlement to service connection for an acquired psychiatric disorder to include anxiety and depression, secondary to service-connected disabilities.

Your VA Disability Rating & ​The Schedule

Let's spend a few minutes talking about how VA arrives at the rating you'll receive once your claim has been adjudicated. The process isn't (or shouldn't be) complex. You have a medical problem you feel is connected to your honorable military service. You file a claim 
seeking compensation for the disabling condition. VA then gathers all pertinent records and any other relevant evidence and schedules you for a 
C & P exam. Once all that is completed, a Ratings Veterans Service Representative (RVSR) will study all of that and issue a rating. 
As the RVSR reviews the evidence, your condition and the amount of disability the condition ​is causing will be derived from

  38 CFR Book C, Schedule for Rating Disabilities .
Much of what you'll find there is in need of updating to reflect a more modern medical approach to illness and injury but for now, The Schedule is what we have to work with. As you file your disability benefits claim you'll want to look at the language VA uses to define different ratings for your specific malady. If you have a knee problem, you'll go to 
4.40 - 4.73 - The Musculoskeletal System  

and then explore until you learn all you ever wanted to know about how VA rates knee injuries.​ The same holds true for any illness or injury you believe is connected to your service. If your specific condition isn't listed, that's not unusual and VA allows for symptoms of a like kind to be rated by similar symptoms of similar conditions. As you perfect your benefits portfolio, you should become familiar with The Schedule. The more you know, the more control you have over your benefits.

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