The Nexus Requirement
“Nexus” is a legal term to say that the current disability (requirement #1) is connected to the in-service injury, event, or medical condition (requirement #2). This is where we see VA denying most veterans’ claims. The most common connection between the two is what’s called a “direct connection.” The in-service condition, event or injury is a direct cause of the current disability. But this is not the only way to establish a connection.
Four Ways to Establish Service Connection
- Direct: There is a direct link between the current condition and the in-service condition, event or injury
- Aggravation: The current condition preexisted service but was aggravated by the veteran’s military service
- Secondary: The current condition is caused by a service-connected disability
- Presumptive: There is a statutory presumption that even though the current disability did not show up during service, it is presumed to be caused by the veteran’s service
The disease or condition does not have to exist or manifest itself during service. Sometimes the VA is very keen to rely on a veteran’s discharge exam to conclude that because the condition did not exist during service, it cannot be related to service. This is false.
The only requirement is “competent evidence” linking the current condition to an in-service condition, injury or event. Some conditions do not manifest themselves until long after a veteran’s career is over. For instance, exposure to loud noises may not cause a noticeable hearing loss until years after a veteran leaves the service. Exposure to toxic substances can cause issues years down the road. Service connection is available for any condition. Proving this connection most often requires medical evidence of a link.
If the veteran entered service with a pre-existing condition, the veteran can still be service-connected for that condition if his/her service made the pre-existing condition worse. 38 U.S.C.S. § 1153. First, though, remember that servicemembers are presumed to be sound when they enter the military. If the condition wasn’t noted at entry, the veteran should be presumed sound. If not, then proving aggravation is the key to service-connection. You can read more about the “presumption of soundness” here.
There is an assumption built into the statute. If the veteran’s pre-existing condition worsens during service, the VA should assume the veteran’s military service caused the decline. The VA can overrule this presumption only where there is a “specific finding” (in other words a medical opinion) that the condition declined because of some natural progression of the disease.
The best evidence to prove aggravation is a record of treatment in service for a worsening condition. A veteran can also seek out a medical opinion comparing the condition’s severity before and after service.
Secondary connection is for conditions caused by a veteran’s already service-connected disability. 38 CFR § 3.310. For instance, medication required for a service-connected disability may have significant side effects. A veteran can also receive a rating for the side-effects incurred as a result of the medication. Or a veteran may develop depression as the result of a service-connected severe physical impairment. The veteran can also be rated for the depression. Lastly, especially in the case of musculoskeletal injuries, a physical impairment in one area of the body (for example a knee which collapses and causes the veteran to walk with a limp) can create secondary effects in the back, hips, and the other leg.
As with proving direct service connection, generally a medical expert’s opinion is required to connect a condition to an already service-connected condition.
The VA will presume that certain chronic conditions, if they were diagnosed in-service or within a certain period of time after service are connected to the veteran’s service. The list of chronic conditions is found in 38 CFR § 3.309 and copied here:
Atrophy, progressive muscular
Calculi of the kidney, bladder, or gallbladder
Cardiovascular-renal disease, including hypertension
Cirrhosis of the liver
Encephalitis lethargica residuals
Endocarditis (This term covers all forms of valvular heart disease)
Lupus erythematosus, systemic
Other organic diseases of the nervous system
Osteitis deformans (Paget’s disease)
Purpura idiopathic, hemorrhagic
Sclerosis, amyotrophic lateral
Thromboangiitis obliterans (Buerger’s disease)
Tumors, malignant, or of the brain or spinal cord or peripheral nerves
Ulcers, peptic (gastric or duodenal)
The default post-service period of time in which the condition can be diagnosed to take advantage of the presumption is one year. So, for instance, if a veteran is diagnosed with arthritis either during service or within one year of the veteran’s discharge (and, of course, still has the arthritis), the VA should presume that the arthritis is service-connected.
For leprosy and tuberculosis the presumptive period is three years. For multiple sclerosis, seven years.
Does the veteran have to show regular symptoms of the chronic condition from the time they exited the service to the present? Yes, but only under certain conditions. Where a condition is formally diagnosed in service the veteran does not need to show continual symptoms. Thus, if a veteran is diagnosed with arthritis in-service but does not experience compensable symptoms until twenty years after service, the VA should presume the current disability of arthritis is service-connected.
However, where the condition is not shown to be chronic or diagnosed beyond legitimate question during service, the veteran must show a continuity of their symptoms from the date of discharge until now. The veteran will need medical, or sometimes lay, evidence of a link between the current disability and the continuous symptoms.
For veterans with service in a tropical location, the VA will presume certain tropical diseases which manifest to at least a 10% rating within 1 year of the veteran’s separation from the service are service-connected. They are:
Leishmaniasis, including kala-azar
Resultant disorders or diseases originating because of therapy administered in connection with such diseases or as a preventative thereof
If the disease is medically known to have such a lengthy incubation period that the symptoms don’t begin until after the one year post-separation period, it is still considered service-connected.
For veterans who were prisoners of war, the VA will presume the following conditions are service-connected if they manifest to at least a 10% degree at any time after the veteran’s service.
Any of the anxiety states
Dysthymic disorder (or depressive neurosis)
Organic residuals of frostbite, if it is determined that the veteran was interned in climatic conditions consistent with the occurrence of frostbite
Atherosclerotic heart disease or hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia)
Stroke and its complications
On or after October 10, 2008, Osteoporosis, if the Secretary determines that the veteran has posttraumatic stress disorder (PTSD)
Did VA Deny Your Claim For a Lack of Nexus?
If VA denied your claim because of a lack of nexus, please contact us for a free evaluation of your claim. Within about 45 days we can obtain your claim file from the VA and perform a free review of VA’s denial and determine what medical evidence is needed to prove the claim.