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Updated Jun 05, 2024

In This Section

 This section contains the following topics:
Topic Topic Name
1 Determining Direct SC
2 Presumption of Soundness and Active Service Requirements
3 Determining Service Incurrence of an Injury

1.Determining Direct SC

Introduction

 This topic contains information on determining direct SC, including

Change Date

 June 5, 2024

V.ii.2.A.1.a.Overview of Direct SC

 Direct service connection (SC) means that a particular disease or injury was incurred in service.  This is accomplished by affirmatively showing inception during service.  There are three components to proving direct SC.  These are
  • a current disability
  • an event, injury, or disease in service, and
  • a link or nexus establishing that the current disability had its onset or inception in service, which may be established by evidence of
All pertinent or relevant medical and lay evidence must be considered, including the service records (which may show the places, types, and circumstances of service and the official history of the organization in which the Veteran served). References:  For more information on

V.ii.2.A.1.b.Satisfying the Current Disability Requirement for SC

 Evidence of a current disability is required as one of the components of establishing SC.  Generally, this criterion is satisfied when a current examination or other evidence demonstrates the presence of a chronic disability.  However, the evidence must be reviewed to determine whether a disability was present at the time the claim was filed or during the pendency of the claim but has since resolved.
  • The requirement for a current disability is met if a disability exists when a Veteran files a claim or while the claim is pending, even though the disability resolves before the Department of Veterans Affairs (VA) decides the claim.
  • A diagnosis that is near-contemporaneous with the filing of a claim must be considered when determining whether a disability existed when the claim was received and/or during its pendency.
    • A near-contemporaneous diagnosis is a diagnosis that is dated approximately within one year prior to the date of the claim being submitted.
    • A diagnosis that predates, but is near-contemporaneous with, a claim is capable of establishing a current disability under the law.
A determination of SC will be made on a case-by-case basis with evaluation of all pertinent evidence.  Consider the history of the diagnosis and give appropriate weight to any diagnosis present near-contemporaneously with or during the pendency of a claim.  The weighing of evidence will generally result in one of the following three possible conclusions:
  • The contemporaneous or near-contemporaneous evidence at or near the time of the claim shows a clear diagnosis.  The current medical evidence (often the compensation examination) shows the disability has resolved and no current diagnosis is warranted.  A grant of benefits is in order, generally with a staged disability evaluation.
  • The contemporaneous or near-contemporaneous evidence at or near the time of the claim suggests or reflects a treating or unconfirmed diagnosis but does not clearly establish whether a confirmed diagnosis was present.  The current medical evidence (often the compensation examination) indicates no diagnosis is currently warranted.  The evidence presently of record does not clearly establish whether the prior diagnosis was or was not warranted.  A medical opinion is necessary to reconcile the status of the prior diagnosis.
  • The contemporaneous or near-contemporaneous evidence at or near the time of the claim shows a diagnosis.  The current medical evidence (often the compensation examination) shows a clear finding that the prior diagnosis was in error and includes adequate rationale.  A denial of SC is warranted, assuming that other medical evidence does not refute the current medical opinion.
Example 1:  A Veteran is diagnosed with eczema regularly throughout service and was treated with topical medications by dermatologists on multiple occasions.  Symptoms waxed and waned, as is typical with eczema, based on seasonal changes.  Service treatment records (STRs) from June 2012 show eczema.  A Benefits Delivery at Discharge claim is submitted, and a VA pre-discharge examination from August 2012 determines that no pathology exists to render a diagnosis of a skin disorder.  The in-service records clearly show a long-standing diagnosis of eczema which was present near-contemporaneously with the claim.  SC should be granted. Example 2:  A Veteran claimed SC for sinusitis in March 2008, prior to military discharge in July 2008.  During service, the Veteran was treated variably for upper respiratory infections, ear infections, deviated septum due to an in-service injury, chronic nasal congestion, and sinus problems.  On examination, the Veteran reported pain and headache in the sinus area and non-incapacitating flare-ups two to three times a year.  The examiner provided no diagnosis and indicated that no sinusitis was shown on exam.  The examiner indicated that there was no visible postnasal drainage or significant hypertrophy or posterior oropharyngeal lymphoid tissue.  The examiner explained that the layman concept of sinusitis or sinus problems is understandable, but in the truest sense, from a specialist’s point of view, there is no underlying chronic sinusitis in this case, especially based on the computed tomography (CT) scans.  The examiner indicated that the in-service symptoms were consistent with acute episodes of upper respiratory infection and/or symptoms of deviated nasal septum.  The evidence of record is sufficient to establish SC for traumatic deviated nasal septum.  There is no medical evidence to refute the examiner’s finding that sinusitis is not shown by the medical evidence of record.  SC for sinusitis should be denied.References:  For more information on

V.ii.2.A.1.c.Establishing Direct SC Under 38 CFR 3.303(a)

 Direct SC may be established under 38 CFR 3.303(a) when
  • the evidence or a medical opinion shows a nexus between a current disability and an injury, disease, or event in service, or
  • competent medical evidence demonstrates continuous symptoms that are sufficient to constitute a nexus between a current disability and an injury, disease, or event in service.
Notes:
  • For any disability shown to be chronic in a medical sense, but not listed in 38 CFR 3.309(a), continuous symptoms may be used to satisfy the nexus element for direct SC under 38 CFR 3.303(a).  When the nexus element is met, a medical opinion is not needed.
  • Continuous symptoms are demonstrated when the medical evidence shows symptoms continuing without stopping, or recurring regularly, with minimal interruptions, from military service.
  • When the evidence shows isolated instances of symptoms which do not demonstrate continuous symptomatology since service, an examination with medical opinion requested in accordance with 38 CFR 3.159(c)(4) may provide the required nexus.
References:  For more information on

V.ii.2.A.1.d.Establishing the Nexus for Direct SC Under 38 CFR 3.303(b)

 The principles of chronicity and continuity discussed under 38 CFR 3.303(b) may be used to satisfy the nexus element for direct SC when the claimed disability is a chronic disease listed under 38 CFR 3.309(a). Important:  If the nexus element is satisfied under 38 CFR 3.303(b) based on chronicity or continuity as discussed in M21-1, Part V, Subpart ii, 2.a.1.e and f, then a medical opinion is not needed to establish SC. References:  For more information on

V.ii.2.A.1.e.Establishing Direct SC Based on Chronicity

 When a chronic disease listed under 38 CFR 3.309(a) is shown in service, consider all subsequent manifestations of the same chronic disease as service-connected (SC), unless there are intercurrent causes to explain post-service manifestations of the chronic disease.  To establish SC under 38 CFR 3.303(b) based on the chronicity of a disease shown in service, the evidence must include
  • manifestations sufficient to identify the disease entity, and
  • evidence sufficient to establish the presence of chronic disability in service as opposed to isolated findings or a diagnosis merely including the word “chronic.”
Example:  Right knee degenerative joint disease (arthritis) first began and was diagnosed during active duty service and was confirmed by x-ray imaging.  The Veteran claims SC for right knee arthritis 10 years after separation.  Medical records dated since separation from service are silent for right knee complaints or treatment, and there is no evidence of post-service right knee injury. Analysis:  Right knee degenerative joint disease is a chronic disability listed under 38 CFR 3.309(a).  The in-service evidence of arthritis diagnosed by x-ray establishes onset and chronicity of the claimed condition.  There is no evidence of an intercurrent cause for the right knee arthritis. Result:  The clear onset of a chronic disability in service satisfies the nexus element for direct SC, and SC can be established under 38 CFR 3.303(b) without a medical opinion. Notes:
  • When the finding of chronicity is in question, evidence of continuity is required to establish SC for conditions listed under 38 CFR 3.309(a).
  • A careful review of the evidence may reveal that chronic disability from a condition had its onset during active duty service and has chronically persisted from active service to the present, even when service medical providers did not conclude that there were residuals or continuation of a disease or injury.
  • For any disability not listed under 38 CFR 3.309(a), SC must be established under 38 CFR 3.303(a) by associating a current disability to service by a nexus consisting of evidence of continuous symptoms or a medical opinion.
Reference:  For more information on chronicity, see

V.ii.2.A.1.f.Establishing SC Based on Continuity of Symptoms

 Continuity of symptomatology satisfies the nexus element of direct SC under 38 CFR 3.303(b), and serves as the evidentiary tool to confirm the existence of the chronic disease while in service.  Continuity of symptomatology under 38 CFR 3.303(b) may only be used to establish SC for a chronic disease listed under 38 CFR 3.309(a).  A showing of continuity for a chronic disability listed under 38 CFR 3.309(a) is only required when
  • the condition noted during service is not, in fact, shown to be chronic, or
  • where chronicity may be legitimately questioned.
Reference:  For more information on continuity of symptoms, see

V.ii.2.A.1.g.Establishing Direct SC Under 38 CFR 3.303(d)

 Consider whether direct SC may be established under 38 CFR 3.303(d), even if SC is claimed for a disease diagnosed after discharge from service.  SC may be awarded for a disease diagnosed after discharge when all the evidence establishes that the disease was incurred in service.

V.ii.2.A.1.h.Definition:  Acute and Transitory

 An acute disability is a disease or injury that
  • has definite symptoms
  • is short in duration, and
  • results in a recovery without apparent residuals.
A transitory disability is a disease or injury that is not permanent. Examples:  Acute and transitory disabilities include
  • nasopharyngitis or catarrhal fever (common cold)
  • pneumonia, or
  • a bruise.
Important:  Do not arbitrarily determine in-service injuries to be acute and transitory without relying on competent medical evidence determining that chronic disability was not demonstrated. References:  For more information on

2.Presumption of Soundness and Active Service Requirements

Introduction

 This topic contains information on determining direct SC, including

Change Date

 August 2, 2022

V.ii.2.A.2.a.Definition: Presumption of Soundness

 The presumption of soundness means that a Veteran will be considered to have been in sound condition (the claimed disability did not exist) when examined, accepted, and enrolled for service. Exceptions:  The presumption of soundness does not apply when the evidence shows
  • defects, infirmities, or disorders noted at entrance into service (such as conditions noted on the entrance examination), or
  • the injury or disease clearly and unmistakably existed prior to service and was not aggravated by service.
Notes:
  • The presumption of soundness applies only when the Veteran underwent a physical examination at the time of entry into service on which the claim is based.
  • Only the conditions that are recorded in the enlistment examination report are to be considered as noted.  A history of pre-service conditions recorded at the time of the entrance examination is not a notation of the condition.  It is just one factor that must be considered on the question of presumption of soundness.
  • The presumption of soundness is also applicable when the Veteran underwent a physical examination upon entrance into service, but the report of examination is unavailable.  In such a situation, the presumption of soundness will stand.  Once the presumption of soundness arises it is only overcome when the record contains clear and unmistakable evidence showing that the disease or injury existed prior to service and was not aggravated by service.
  • A defect, infirmity, or disorder noted on the enlistment examination must meet established criteria and/or definitions of disability to overcome the presumption of soundness.  For example, audiometric data documenting the existence of abnormal hearing but not to the extent satisfactory to meet the definition of hearing loss for VA purposes as specified in 38 CFR 3.385 would not overcome the presumption of soundness.  To establish that there was a hearing loss existent at enlistment, the audiometric data must document hearing loss for VA purposes as defined in 38 CFR 3.385.
Reference:  For more information on the presumption of soundness and aggravation, see

V.ii.2.A.2.b.Service Requirements for Presumption of Soundness

 Use the table below to determine the service requirements the Veteran must meet before VA can apply the presumption of soundness.
If the Veteran served during … Then the Veteran must …
peacetime before January 1, 1947 have had active continuous service of six months or more, per 38 CFR 3.305(b).
  • peacetime on or after January 1, 1947, or
  • wartime
 meet no minimum service requirements, per 38 CFR 3.304(b).

V.ii.2.A.2.c.Considering the Presumption of Soundness at Entry Into Service

 Under 38 U.S.C. 1111, when no pre-existing condition is noted at entrance into service, then the presumption of soundness establishes that the claimed disability did not exist before service unless there is clear and unmistakable (undebatable) evidence showing that the disease or injury which manifested in service
  • existed prior to service, and
  • was not aggravated by service.
Notes:
  • Personality disorders are not considered diseases or injuries under 38 U.S.C. 1110; therefore presumption of soundness under 38 U.S.C. 1111 pertaining to personality disorders does not apply.
  • The presumption of soundness still requires evidence of a nexus between a current disability and the in-service disease or injury.

V.ii.2.A.2.d.Definition: Active Continuous Service

 Active continuous service may exclude lengthy periods of extended absence from duty, such as unauthorized absence or other extended non-pay status. A determination of whether a period of unauthorized absence is considered a break in service should be undertaken on a case-by-case basis with consideration of the facts of the individual’s case, including the extent to which the circumstances, nature, and duration of the claimant’s absence affected his or her performance of continuous duty. Examples:  The following facts and findings are set forth in General Counsel (GC) Opinions:
  • In GC Advisory Opinion Op. G.C. 4-80, the service member was absent from duty for 1,344 days before returning to military control.  The Veteran received an honorable discharge nine days later and developed a chronic disease within one year of discharge.  Since the Veteran was without active, continuous service for all but nine days of the 3-3/4 years preceding separation, the continuous service requirement of 38 CFR 3.307 was not met.
  • In Precedent Opinion VAOPGCPREC 11-1993, the service member voluntarily returned to his unit after 13 days of unauthorized absence.  Although the 13 days of unauthorized absence was not creditable for pay or time-in-service purposes, it did not constitute a break in service for purpose of the “active, continuous service” requirement under 38 CFR 3.307.

V.ii.2.A.2.e.Applying the Presumption of Soundness for ADT

 In claims based on a period of active duty for training (ADT), apply the presumption of soundness only when the Veteran underwent a physical examination at the time of entry into the period of ADT on which the claim is based. If an examination was performed, consider the Veteran to have been in sound condition when entering ADT except as to defects, infirmities, or disorders noted on the examination report. Important:  The presumption of soundness is only triggered for a period of ADT when an examination has been conducted if the claimant has previously established Veteran status, which is defined as having prior active military service, and was discharged under conditions other than dishonorable.  Neither the presumption of soundness nor aggravation may be applied if the claimant does not have Veteran status.
Reference:  For more information on the presumption of soundness in claims based on ADT, see Smith (Valerie Y.) v. Shinseki, 24 Vet.App. 40, 44 (2010).

V.ii.2.A.2.f.Requirements for IADT to Be Considered Active Service

 Inactive duty training (IADT) is not considered active service unless SC is awarded for disability or death resulting from
  • an injury directly incurred during the period of inactive duty training, or
  • an injury or one of the following events if the injury or event occurred during inactive duty training or while an individual was proceeding directly to, or returning directly from, a period of such training
    • an acute myocardial infarction
    • a cardiac arrest, or
    • a cerebrovascular accident.
Notes:
  • If evidence establishes that an individual suffers from a disabling condition as a result of the administration of an anthrax or Coronavirus disease (COVID-19) vaccine during IADT, the individual may be considered disabled by an “injury” incurred during such training.
  • An individual who suffers from posttraumatic stress disorder (PTSD) as a result of military sexual trauma (MST) that occurred during a period of IADT may be considered disabled by an injury for purposes of 38 U.S.C. 101(2) and (24).
References:  For more information on

3.Determining Service Incurrence of an Injury

Introduction

 This topic contains information on determining service incurrence of an injury, including

Change Date

 January 20, 2016

V.ii.2.A.3.a.Substantiating the Circumstances of Injuries

 The development activity and/or rating activity must review the evidence of record, to include personnel records and STRs, to ensure the injury occurred during service and in the line of duty (LOD). Rationale:  The results of injuries, including gunshot wounds acquired before or after service, are frequently encountered and would not be granted SC as they are not injuries that occurred during service or in the LOD. Reference:  For more information on willful misconduct and LOD determinations, see M21-1, Part X, Subpart iv, 1.C.

V.ii.2.A.3.b.Evaluating Evidence of Scars

 When evaluating evidence of scars, keep in mind that a claimant may have
  • been accepted into service with a notation of one or more scars existing at the time of entrance
  • sustained a wound, with a resulting scar, during service, or
  • received an injury following separation from service resulting in a scar that would be present at subsequent physical examinations.
Because the Veteran could have incurred a scar before or after service, exercise caution in characterizing a scar as the residual of a wound or injury incurred in service. If there is any doubt as to whether the scar is a residual of a wound or injury incurred in service, simply describe the scar, without ascribing it to a specific injury such as a “gunshot wound” or “shrapnel wound.”

V.ii.2.A.3.c.Processing Examination Reports of Scars

 If the presence of a scar or scars is recorded in a physical examination report related to a claim for scarring, review official records to ensure the scar or scars are in fact a residual of wounds in service. If there is reasonable doubt as to whether the scar(s) are related to service, that is, an approximate balance of evidence for and against the claim, award SC for the claimed scar(s). References:  For more information on

V.ii.2.A.3.d.Considering Evidence for Combat-Related Disabilities

 Accept satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat 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. In order for evidence submitted by the Veteran to support a factual presumption that the claimed disease or injury was incurred or aggravated in service, the evidence must
  • be satisfactory when considered alone
  • be consistent with the circumstances, conditions, or hardships of such service, and
  • not be refuted by clear and convincing evidence to the contrary.
Notes:
  • 38 CFR 3.304(d) is derived from 38 U.S.C. 1154(b), and lightens the evidentiary burden with respect to disabilities alleged to be the result of combat service.
  • Even when an event or injury in service is established under the cited combat provisions, for SC to be established there must still be evidence of a current disability and a nexus between the current disability and the combat event or injury in service.
References:  For more information on

V.ii.2.A.3.e.Definition: Satisfactory Evidence

 Satisfactory evidence generally means evidence that is credible. It is proper to
  • consider internal consistency and plausibility in determining whether evidence is credible, and
  • regard statements that contradict other evidence of record as unsatisfactory.
Reference:  For more information on determining whether evidence is credible, see