As the title of the regulation suggests, there are two categories of claims that can be granted secondary service connection under VA regulation 3.310,
“Disabilities that are proximately due to, or aggravated by, service-connected disease or injury.”
The first category includes claims for which there is an initial service-connected disability, and then a subsequent disability or disabilities found to be proximately due to (caused by) the service-connected disability. One example of this type of claim would be loss of limb due to amputation occurring subsequent to a service-connected diabetes diagnosis.The loss of a limb, it might be argued, should be service connected in addition to the diabetes because the amputation may not have been needed had the veteran not developed diabetes.
In the two-year period from October 2004 through September 2006, nearly 260,000 veterans were service connected for conditions proximately due to service-connected disabilities. This accounted for approximately 19 percent of the more than 1.3 million disabilities that were service connected during that period. Most of the disabilities were rated at 10 or 20 percent. Less than 10 percent were rated at 50 percent or higher.
Ten conditions accounted for 55 percent of the disabilities compensated as secondary to service-connected disabilities in 2005–2006.
In accord with a 1995 court decision (Allen v. Brown, 7 Vet. App. 439), VA will also grant service connection under this regulation in claims where there is an increase in the severity of nonservice-connected disability that is found to be due to aggravation by a service-connected disability. These are called secondary service connection by aggravation claims or, after the
In people with diabetes, an increased risk of amputation comes from damage to nerves and blood vessels through decreased circulation efficiency and diabetic neuropathy. According to the American Diabetes Association, more than 60 percent of nontraumatic lower-limb amputations occur in people with diabetes and the rate of amputation for people with diabetes is 10 times higher than for people without diabetes (ADA, 2007).
What Is a Secondary Condition?
Secondary condition is a relatively new term in the disability and public health arenas. It began to be accepted around 1990 as an expansion of the concept of comorbidity, which is used to refer to conditions that exist in a single person simultaneously, but that are not known to be related in any manner (CDC, 2004a). A person having coexisting skin malignancy and hearing loss would be said to have comorbidities, because there is no known relationship between these two conditions.
From a strictly medical perspective, a secondary condition is a condition with its own pathophysiology that is due to, or caused by, the presence of a preceding primary condition. Secondary conditions can be distinguished from secondary manifestations, the latter referring to sequelae or subsequent complications arising from the same underlying pathophysiologic process as the primary condition.
Diabetes is a good example of a condition with many secondary manifestations. Diabetes itself is an abnormal metabolism of glucose (that can be induced in several ways, including trauma), which has an associated abnormality in lipid metabolism, which leads to an accelerated process of arteriosclerosis. This combination leads to a higher frequency and earlier onset of, among other things, peripheral vascular disease, coronary arteriosclerosis, peripheral neuropathy, and premature cataracts of the eyes. These can be considered secondary manifestations because they are expressions of the person’s underlying diabetes and share the same underlying pathophysiology.
At times the Rating Schedule treats what are in fact secondary manifestations as secondary conditions. The instructions on rating diabetes mellitus (diagnostic code 7913 under CFR 4.119 Schedule of ratings—endocrine system), for example, tell raters to evaluate compensable complications of diabetes separately, except in cases where they are a part of a 100 percent
evaluation (diabetes ratings below 100 percent do not take into account compensable complications).
Rating Secondary Service Connection Claims
In a presentation before the committee, C&P Service staff stated that decisions on secondary claims are based on the facts of the individual case and the medical opinion solicited from the VHA examiner on the general medical examination form. Using this evidence, the rater determines whether it is at least as likely as not that each claimed secondary condition was caused by the primary service-connected condition.
The process of assigning ratings in secondary claims is the same as in claims involving multiple individually service-connected conditions. Each condition is first evaluated separately and assigned a percentage rating. Starting with the condition with the highest percentage rating, the rater then uses VA’s combined ratings table to calculate an overall percentage rating for the primary condition and all conditions found to be proximately due to the primary condition.
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