Courtney Ross: Good afternoon and welcome to Facebook Live with Chisholm Chisholm & Kilpatrick.
I'm Courtney Ross. I'm joined today by Alyse Galoski and Alec Saxe. Today, we're going
to be talking about diabetes. So, I want to get started just by generally talking about
what diabetes is. So, there're two types: Type 1 and Type 2. For purposes of this broadcast,
we're going to really be focused on Type 2 diabetes which is a chronic condition that
affects the body's blood glucose levels due to either insulin deficiency or being insulin
resistant. Type 1 is a similar condition but it typically develops in adolescence so you
usually have it earlier on in your life. And for VA adjudication purposes, there's actually
a distinction between Type 1 and Type 2. We're going to get to this later in the broadcast
which is to give you an example, Type 2 diabetes is a condition that VA will presume is due
to the veteran's exposure to herbicides and Agent Orange where Type 1 is not for that
same presumption. So, the severity of the condition can vary case by case. Some individuals
are able to control Type 2 diabetes with a restricted diet while other people have a
more difficult time doing that. As the condition progresses, it can become a little bit more
difficult to really control those blood glucose levels. So, for veterans who may already be
service-connected for this type of condition, it's important to kind of monitor how your
disease progresses because the more severe it gets, you may be entitled to a higher rating
from VA, which means additional compensation for that benefit. And that's kind of a good
segway into the next thing I want to talk about, which is, how VA rates Type 2 diabetes.
What they're looking at to decide what rating is appropriate for a veteran's condition.
So, Alyse, can you talk a little bit about that?
Alyse Galoski: Sure. So there are various different ratings that you could get for Type
2 diabetes. They range from a 10% rating all the way up to 100% rating and as Courtney
was touching upon it, a big factor is how you are having to control your diabetes. A
10% rating, for example, would be somebody who can control it just with a restricted
diet, whereas, 20% is someone who requires a restricted diet or they require a certain
exercise routine or they require insulin. Then we go up to 40% based on how often you
might need that insulin, if you need it more than just once a day. You may-- you're starting
to look into those higher ratings. You're also looking at some reactions that you might
have in the higher ratings. For example, if you are hypoglycemic, if you have those types
of reactions, that's when you're going to start getting into those 40%, 60%. Excuse
me, 60% ratings, 100% ratings. You can also suffer complications from your diabetes. For
example, we're going to touch upon this a little bit later but maybe if you have an
eye condition or a neuropathy condition, the rating criteria right in the criteria tells--
directs adjudicators that they are to rate those complications separately so long as
they basically come up to a compensable level. But if you have ratings, excuse me, if you
have complications rather that are not what VA would consider compensable, that may entitle
you to a 60% rating. Hospitalizations also come into effect if you are having to be hospitalized,
that might warrant a 100% rating. So these are just the factors but a very common theme
that we're seeing that Courtney touched upon is how you are actually having to control
and manage your blood sugar levels.
Courtney: Thank you, Alyse. So, I want to back up a little bit. We talked about how
VA rates diabetes once a veteran is service-connected for it. Let's back up a little bit and talk
about ways to actually get service-connection for diabetes. So, Alec, can you talk a little
bit about one way that a veteran might be able to seek.
Alec Saxe:Sure. Yes, of course. As we touched on the most prevalent way we see a
veteran becomes service-connected for diabetes-related to service is through the exposure to these
harmful chemical herbicides, specifically, Agent Orange and that would be for veterans
who serve with boots on the ground on in the inland waterways of Vietnam, specifically
between these certain dates that VA has set, January 9, 1962, and May 7, 1975. If you are
a veteran who served, again boots on the ground in the Republic of Vietnam, or in the waterways
which I'll expand on a little later, VA presumes that you are exposed to those harmful chemical
agents and if you have the diagnosis of diabetes, then you're entitled to service-connection
and disability compensation benefits for it. So, for a long time, no one really knew what
these inland waterways were up until recently really, last year the Federal Circuit in a
case called Procopio, decided that under the statute and the term of Republic of Vietnam
and what does that refer to, it's built its landmass but also a 12-nautical mile territorial
sea, seaward of the demarcation line of Vietnam which is a little technical. We have some
literature on our website and some visual representations that can kind of help you
out with that territory off the coast of Vietnam. So, Congress has essentially codified the
decision and now called the Blue Water Navy Vietnam Veterans Act. So, VA terms it if you
are a Blue Water Navy Veteran, again, who served within this 12-nautical-mile range
between the same dates, again, January 1962 and May 1975, you are entitled to that same
presumption that your fellow veterans who have boots on the ground receive. So, again,
those are the common ways this exposure to Agent Orange as a Vietnam era veteran but
in addition to that, veterans who flew on or worked on specific aircraft C-123's between
1969 and 1986, these aircraft are used to spray the actual chemical Agent Orange over
the forested areas in Vietnam during Operation Ranch Hand. So, if you were a part of that
operation or working on those aircraft, that presumption can extend to you. We have information,
again, on that on our website. So, in addition to that, we have veterans who served near
the Korean DMZ or along the DMZ between September 1967 and August 1971, actually, the Blue Water
Act recently expanded those dates as well. So, those are the dates 1967 to 1971. And
then last, we have Thailand. If you served on or near Thailand military bases between
February 1961 and May 1975, again, Agent Orange was used to spray the surrounding forested
areas in preparation for attacks from the enemy. So, there's bountiful evidence that
veterans serving in those Thailand military bases were exposed to Agent Orange and they're
presumed to have the presumption as well. So, those are all the chemical herbicides,
Agent Orange links. In addition to that, I'll just note that VA considers diabetes a chronic
disease under 38 CFR 309/7, both of them, I think. So, if you developed diabetes within
a year of your discharge, you may be entitled to service connection and compensation benefits
for that.
Courtney: Yes. We've recently done some other Facebook Live videos that specifically
discuss the Blue Water Navy Act and the recent extension of the presumption of exposure to
those veterans as well. So, you can check those out on our website as well. So, you
talked a lot about presumptive service connection, one other way that you may be able to seek
service connection for diabetes is as a secondary condition. Secondary service connection means
getting service connection for a condition that developed not as duty or service but
instead as due to a condition that you're already service-connected for. So, one of
the most common ones that we see with diabetes is the development of diabetes being caused
by sleep disorders or sleep apnea. VA and DOD, or the Department of Defense, actually
did a study that showed individuals with sleep apnea or poor sleep quality typically develop
diabetes. So, for sleep apnea, it actually increases the risk of diabetes by 78% which
is a pretty significant number. And those that have trouble sleeping had a 21% increase
in terms of a risk of developing diabetes. So, there's a significant connection there.
That's just one example. It could be possible that there's other conditions that may cause
or reach the development of diabetes as well. So, in addition to considering trying to connect
diabetes directly to the time of service or as a presumptive condition due to exposure,
you should also consider whether the condition may have developed later in life and may be
connected to a condition you're already getting service-connected benefits for from VA. Another
example is actually drugs that may be prescribed to you to treat things like high cholesterol
or a heart condition. So, if you are already service-connected for a heart condition, there
may be certain drugs that you're taking for that condition that can actually increase
the risk of diabetes as well. There's medical literature that supports the possible connection
there too. So this is just a different way that you may be able to get service-connected
from diabetes. So, just other things that you want to consider as well. A third way
which relates to secondary service connection but isn't exactly the same is actually using
obesity as an intermediate step. Alyse, can you talk a little bit about what is meant
by that?
Alyse: Sure. Just as a general matter, obesity is not actually a disability for VA
purposes. So, you cannot receive service connection for obesity; however, you can use obesity
as you had just said, Courtney, as an intermediate step to get your secondary service connection.
And this is really a hot button topic right now and the reason for that is that obesity
is very common among the veterans' population and so is diabetes. The reason for that is
that they're actually linked. If you have obesity, you are more prone to develop Type
2 diabetes and a lot of veterans do suffer from obesity due to multiple reasons, whether
they have different disabilities that preclude exercise or they're on certain medication,
or whatever it might be. So, the court has recently determined that you can't get service-connected
for obesity but you can have that linked. So, what that would mean is if you have a
condition that is service-connected that causes your obesity and then your obesity causes
diabetes, you can use that as a link to get the secondary service connection. So, for
a specific example, maybe you have a severe knee disability that prevents you from being
able to move around a lot. As a result, you have become obese, and as a result of obesity,
you have developed diabetes. So, as long as that knee condition is service-connected,
the diabetes can be service-connected. So, you can't get direct service connection
from obesity but it is a useful tool to get you service-connected for a different condition
that you might have developed.
Courtney: That's really helpful. So, something else to consider and think about if you're
suffering from diabetes and you're looking to try to get VA benefits. I just want to
pause quickly and remind our viewers that if you have any questions throughout the broadcast,
please feel free to leave the questions in the comments section. We'll do our best to
answer them as we go. So, we've talked a little bit about secondary service connection for
diabetes. So, getting benefits for diabetes as due to an already service-connected condition,
I want to switch gears now and talk about, and Alyse alluded to this a little bit in
the beginning of the broadcast, conditions that may have developed due to your diabetes.
So, these conditions you may be able to get service-connected for secondary to your diabetes
once that's service-connected. So, Alec, can you talk a little bit about what some of those
conditions are and what are the most common examples.
Alec: Sure. So, according to VA actually, diabetes is the leading cause of blindness,
end-stage renal disease, and amputation for VA patients. Some other common conditions
we see secondary to diabetes are diabetic peripheral neuropathy which is characterized
by weakness, numbness, pain from nerve damage, and typically, we see that in the extremities.
There's also renal or kidney dysfunction; diabetic retinopathy which refers to damage
to the retinas of your eyes, can be caused by diabetes as well as other eye conditions
actually such as cataracts; erectile dysfunction; cardiac conditions such as coronary artery
disease, heart attacks, strokes, and this one is always hard for me to pronounce, arteriosclerosis,
it's a build-up of fat cholesterol in your arteries so that's kind of linked with the
heart disease there, and then hypertension or high blood pressure. There are skin
conditions sometimes as well that can be secondary to diabetes.
Courtney: And so, while you may be able to only get maybe a 20% for your diabetes
under the criteria that Alyse talked about before, if you're also suffering from any
of these other conditions and you're able to establish to VA that it is due to your
diabetes, again as Alyse alluded before, you should get separate rating for each of these
conditions which should increase your overall combined rating and therefore, you're monthly
compensation that you'll get from VA. So, it's really important to kind of keep this
in mind too if you do have the condition and you start to develop some of these other conditions.
You want to make sure that you're aware of this and possibly file a claim with the VA
for them as well. So, just, generally speaking, starting with service connection, if a veteran
is seeking service connection for diabetes, what are the types of evidence that he or
she can submit to VA to help establish the service connection?
Alyse: Sure. The number one type specifically with diabetes is going to be medical evidence
whether it's from your VA treatment provider or from your own private physician. The reason
for that being that, especially rating criteria, it's very technical. It has to do with what
you're prescribed, what you're required to do. While lay evidence might be helpful in
certain situations, I think you really do want to get some of that medical evidence
for these diabetes cases because you will be running into competency issues you aren't
working with the doctor. Other types of evidence like you might attend what's called a VA exam,
we've done multiple-- or we've touched upon this in multiple Facebook Lives, VA exams
are extremely important. They will order one for you. If they order one for you, please
attend them and that's going to be another way that you'll be able to get evidence and
they will ask you questions if it's service connection. They'll probably ask you questions
about when you look into your file as to when you started to experience the diabetes. They
will also look and see if you have any exposure or any other risk factors. If it's an increased
rating claim, they'll probably be more looking at how you're treating whether you have weight
loss, if you have any hospitalizations, any other factors that are going to go into our
rating you would be entitled to.
Courtney: Yes and you could also consider getting your own outside medical opinion as
well. Sometimes VA exams come back negative and don't support your case so you can get
your own opinion, especially if you are trying to link your diabetes to an already service-connected
condition or if you're trying to link some of those conditions we talked about that's
secondary to your diabetes. For those, you're going to need a nexus medical opinion,
specifically if you're attributing those conditions to diabetes or your diabetes to the other
condition. And so, getting outside medical opinion might help you to establish that element
of service connection. The benefit of presumptive service connection, if you are a veteran who
was exposed to herbicides including Agent Orange, is that you really only need to establish
either show you fit within the presumptive exposure periods and then the diagnosis so
you don't have to include that nexus element but for the other service-connection avenues
you will. So, that's important to keep in mind too. Alec, do you have anything additional
in terms of evidence that might be helpful?
Alec: No. I just want to echo that diabetes is a more specialized condition as we say
it's really not capable of lay observation. So, it's not like an orthopedic condition
or your knee hurts, something that happens where residuals from a gunshot wound that
caused your knee to hurt. You can't really observe that. So, that's why you need a statement
from the doctor whether a VA doctor or a private physician as we noted and that nexus to either
another service-connected condition or service in general. So, I think that kind of hits
on the key point.
Courtney: Yes. I think that's a great transition to final thoughts. Alyse, do you have anything
to add in terms of final thoughts.
Alyse: Yes, I would say that diabetes is unique, the rating criteria in that they do
specifically direct the adjudicators to separately rate any complications that you might have;
however, I wouldn't just totally rely on that to assume that they will automatically separately
rate your conditions. So, what that means is I would work with your attorney or your
VSO rep and figure out how you want to file claims for those conditions that are secondary.
It kind of just protects you because even though they are directed to do so, they might
miss it.
Courtney: All right. Well, that's all that we have for you. Thank you for joining us
on Facebook Live with Chisholm Chisholm & Kilpatrick.