evaluation of the same manifestation under different diagnoses are to be avoided. § 4.15 Total disability ratings. The ability to overcome the handicap of disability varies widely among individuals. The rating, however, is based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. How. ever, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effect of combinations of disability. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation; Provided, That permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. The following will be considered to be permanent total disability: the permanent loss of the use of both hands, or of both feet, or of one hand and one foot, or of the sight of both eyes, or becoming permanently helpless or permanently bedridden. Other total disability ratings are scheduled in the various bodily systems of this schedule. § 4.16 Total disability ratings for compensation based on unemployability of the individual. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities; Provided that, If there is only 1 such disability, this disability shall be ratable at 60 percent or more, and that, if there are 2 or more disabilities, there shall be at least 1 disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as 1 disability; (a) Disabilities of 1 or both upper extremities, or of 1 or both lower extremities, including the bilateral factor, if applicable, (b) disabilities resulting from common etiology or a single accident, or (c) disabilities affecting a single body system, e.g., digestive, respiratory, cardiovascular-renal, neuropsychiatric, or (d) multiple injuries incurred in action. It is provided further that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this section for the serviceconnected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the veteran unemployable. § 4.17 Total disability ratings for pension based on unemployability and age of the individual. For the purpose of pension, the permanence of the percentage requirements of § 4.16 is a requisite. The percentage requirements, however, are reduced, on the attainment of age 55, to a 60 percent rating for 1 or more disabilities, with no percentage requirement for any 1 disability. The requirement at age 60 will be a 50 percent rating for 1 or more disabilities. At age 65, there will be no percentage requirement other than 1 disability ratable at 10 percent or more. When these reduced percentage requirements are met, and the disabilities involved are of permanent nature, rating as permanently and totally disabled will be assigned if the veteran is determined to be unable to secure and follow substantially gainful employment by reason of such disability. Prior employment or unemployment status is immaterial if in the judgment of the rating agency veteran's disabilities render him unemployable. In making such determinations, the following will be used as guides: (a) Marginal employment, for example, on own farm, in own business, or at odd jobs, at less than half the usual hours of work or less than half the usual remuneration will not be considered incompatible with a determination of unemployment and unemployability, if the restriction, as to securing or retaining better employment, is due to the disabilities. (b) The fact that unemployable persons meeting the percentage standards have also physical, mental, or personality defects of congenital or developmental nature, which may be a partial cause of the unemployability, will not preclude favorable rating. (c) As it is the policy of the Administration that all veterans who are basically eligible and who are unable to secure and follow a substantially gainful occupation by reason of disabilities which are likely to be permanent shall be rated as permanently and totally disabled for the purposes of pension, therefore, the cases of all veterans who fail to meet the percentage standards, who meet basic entitlement criteria, but who are unemployable, will be referred to Central Office under § 3.321 (b) of this chapter, with statement as to unemployability by the rating board. § 4.17a Misconduct etiology. A permanent and total disability rating under the provisions of §§ 4.15, 4.16, and 4.17 will not be precluded by reason of the coexistence of misconduct disability when (a) A veteran, regardless of employment status, also has innocently acquired 100 percent disability, or (b) Where unemployable, he has other disabilities innocently acquired which meet the percentage requirements of §§ 4.16 and 4.17 and would render, in the judgment of the rating agency, the average person unable to secure or follow a substantially gainful occupation. Meritorious cases of veterans meeting the specifications in this section except they do not meet the percentage standards of §§ 4.16 and 4.17, will be referred to Central Office under § 3.321 (b) of this chapter. A veteran may be considered as unemployable upon termination of employment which was provided for him on account of his disability, or in which special consideration was given on account of the same, when it is satisfactorily shown that he is unable to secure further employment. With amputations, sequelae of fractures and other residuals of traumatism shown to be of static character, a showing of continuous unemployability from date of incurrence, or the date the condition reached the stabilized level, is a general requirement in order to establish the fact that present unemployability is the result of the disability. However, consideration is to be given to the circumstances of employment in individual cases, and, if the employment was only occasional, intermit 86-084-68-15 tent, tryout or unsuccessful, or eventually terminated on account of the disability, present unemployability may be attributed to the static disability. Where unemployability for pension previously has been established on the basis of combined service-connected and non-serviceconnected disabilities and the serviceconnected disability or disabilities have increased in severity, § 4.16 is for consideration. § 4.19 Age in service-connected claims. Age may not be considered as a factor in evaluating service-connected disability, and unemployability, in service-connected cases, associated with advancing age or intercurrent disability, may not be used as a basis for a total disability rating. Age, as such, is a factor only in evaluations of disability not resulting from service, i.e., for the purposes of pension. § 4.20 Analogous ratings. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. § 4.21 Application of rating schedule. In view of the number of atypical instances it is not expected, especially with the more fully described grades, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. § 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. § 4.23 Attitude of rating officers. It is to be remembered that the majority of applicants are disabled persons who are seeking benefits of law to which they believe themselves entitled. In the exercise of his functions, the rating officer must not allow his personal feeling to intrude; an antagonistic, critical, or even abusive attitude on the part of a veteran should not in any instance influence the officer in the handling of the case. Fairness and courtesy must at all times be shown to ex-servicemen by all employees whose duties bring them in contact, directly or indirectly, with the Administration's claimants. § 4.24 Correspondence. All correspondence relative to the interpretation of the schedule for rating disabilities, requests for advisory opinions, questions regarding lack of clarity or application to individual cases involving unusual difficulties, will be addressed to the Director, Compensation and Pension Service. A clear statement will be made of the point or points upon which information is desired, and the complete case file will be simultaneously forwarded to Central Office. Rating agencies will assure themselves that the recent report of physical examination presents an adequate picture of the veteran's condition. Cases in regard to which the schedule evaluations are considered inadequate or excessive, and errors in the schedule will be similarly brought to attention. § 4.25 Combined ratings table. The combined ratings table results from the consideration of the efficiency of the individual as affected first by the most disabling condition, then by the less disabling condition, then by other less disabling conditions, if any, in the order of severity. Thus, a person having a 60 percent disability is considered 40 percent efficient. Proceeding from this 40 percent efficiency, the effect of a fur ther 30 percent disability is to leave only 70 percent of the efficiency remaining after consideration of the first disability, or 28 percent efficiency altogether. The individual is thus 72 percent disabled, as shown in the table opposite 60 percent and under 30 percent. To use the combined ratings table, the disabilities will first be arranged in the exact order of their severity, beginning with the greatest disability and then combined with use of the table as hereinafter indicated. For example, if there are 2 disabilities, the degree of 1 disability will be read in the left column and the degree of the other in the top row, whichever is appropriate. The figures appearing in the space where the column and row intersect will represent the combined value of the 2. This combined value will then be converted to the nearest number divisible by 10, and combined values ending in 5 will be adjusted upward. Thus, with a 50 percent disability and a 30 percent disability, the combined value will be found to be 65 percent, but the 65 percent must be converted to 70 percent to represent the final degree of disability. Similarly, with a disability of 40 percent, and another disability of 20 percent, the combined value is found to be 52 percent, but the 52 percent must be converted to the nearest degree divisible by 10, which is 50 percent. If there are more than 2 disabilities, the disabilities will also be arranged in the exact order of their severity and the combined value for the first 2 will be found as previously described for 2 disabilities. This combined value, exactly as found in the combined ratings table, will be combined with the degree of the third disability (in order of severity). The combined value for the 3 disabilities will be found in the space where the column and row intersect, and if there are only 3 disabilities will be converted to the nearest degree divisible by 10, adjusting final 5's upward. Thus, if there are 3 disabilities ratable at 60 percent, 40 percent, and 20 percent, respectively, the combined value for the first 2 will be found opposite 60 and under 40 and is 76 percent. This 76 will be combined with 20 and the combined value for the 3 is 81 percent. This combined value will be converted to the nearest degree divisible by 10 which is 80 percent. The same procedure will be employed when there are 4 or more disabilities. (See Conbined Ratings Table.) 45. 51 56 46. 51 57 47 52 58 63 48. 53 58 64 49. 54 59 64 69 50. 51. 52. 55 60 65 70 56 61 66 71 57 62 66 71 53 54. 55. 56. 57. 58. 59 60. 61. 62 63. 64. 65. 66. 67 68 69 70. 71. 72. 73. 74. 75. 76. 77 78. 79 80 81 82. 83 84. 85 86. 87 88. 89. 90. 91. 92. 93. 94. § 4.26 62 67 73 78 84 89 95 62 68 73 78 84 89 95 68 74 79 84 89 95 69 74 79 84 90 95 75 80 85 90 95 75 80 85 90 95 76 80 85 90 95 76 81 86 90 95 58 62 67 72 77 81 86 91 95 59 63 68 72 77 82 86 91 95 60 64 69 73 78 82 87 91 96 60 65 69 74 78 82 87 91 96 61 66 70 74 79 83 87 91 96 62 66 71 75 79 83 87 92 96 63 67 71 75 80 84 88 92 96 64 68 72 76 80 84 88 92 96 65 69 73 77 81 84 88 92 96 66 70 73 77 81 85 89 92 96 67 70 74 78 82 85 89 93 96 68 71 75 78 82 86 89 93 96 69 72 76 79 83 86 90 93 97 69 73 76 80 83 86 90 93 97 70 74 77 80 84 87 90 93 97 71 74 78 81 84 87 90 94 97 72 75 78 81 85 88 91 94 97 73 76 79 82 85 88 91 94 97 74 77 80 83 86 88 91 94 97 75 78 80 83 86 89 92 94 97 76 78 81 84 87 89 92 95 97 77 79 82 84 87 90 92 95 97 78 80 83 85 88 90 93 95 98 78 81 83 86 88 90 93 95 98 79 82 84 86 89 91 93 95 98 80 82 85 87 89 91 93 96 98 81 83 85 87 90 92 94 96 98 82 84 86 88 90 92 94 96 98 83 85 87 89 91 92 94 96 98 84 86 87 89 91 93 95 96 98 85 86 88 90 92 93 95 97 98 86 87 89 90 92 94 95 97 98 87 88 90 91 93 94 96 97 99 87 89 90 92 93 94 96 97 99 88 90 91 92 94 95 96 97 99 89 90 92 93 94 95 96 98 99 90 91 92 93 95 96 97 98 99 91 92 93 94 95 96 97 98 99 92 93 94 95 96 96 97 98 99 93 94 94 95 96 97 98 98 99 94 94 95 96 97 97 98 99 99 95 95 96 96 97 98 98 99 99 Bilateral factor. When a partial disability results from disease or injury of both arms, or of both legs, or of paired skeletal muscles, the ratings for the disabilities of the right and left sides will be combined as usual, and 10 percent of this value will be added (ie., not combined) before proceeding with further combinations, or converting to degree of disability. The bilateral factor will be applied to such bilateral disabilities before other combinations are carried out and the rating for such disabilities including the bilateral factor in this section will be treated as 1 disability for the purpose of arranging in order of severity and for all further combinations. For example, with disabilities evaluated at 60 percent, 20 percent, 10 percent and 10 percent (the two 10's representing bilateral disabilities), the order of severity would be 60, 21 and 20. The 60 and 21 combine to 68 percent and the 68 and 20 to 74 percent, converted to 70 percent as the final degree of disability. (a) The use of the terms "arms" and "legs" is not intended to distinguish between the arm, forearm and hand, or the thigh, leg, and foot, but relates to the upper extremities and lower extremities as a whole. Thus with a compensable disability of the right thigh, for example, amputation, and one of the left foot, for example, pes planus, the bilateral factor applies, and similarly whenever there are compensable disabilities affecting use of paired extremities regardless of location or specified type of impairment. (b) The correct procedure when applying the bilateral factor to disabilities affecting both upper extremities and both lower extremities is to combine the ratings of the disabilities affecting the 4 extremities in the order of their individual severity and apply the bilateral factor by adding, not combining, 10 percent of the combined value thus attained. (c) The bilateral factor is not applicable unless there is partial disability of compensable degree in each of 2 paired extremities, or paired skeletal muscles. § 4.27 Use of diagnostic code numbers. The diagnostic code numbers appearing opposite the listed ratable disabilities are arbitrary numbers for the purpose of showing the basis of the evaluation assigned and for statistical analysis in the Veterans Administration, and as will be observed, extend from 5000 to a possible 9999. Great care will be exercised in the selection of the applicable code number and in its citation on the rating sheet. Each service-con nected compensable disability or the major pensionable nonservice disability is to be assigned its diagnostic code number. No other numbers than these listed or hereafter furnished are to be employed for rating purposes, with an exception as described in this section, as to unlisted conditions. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: The first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be "99" for all unlisted conditions. This procedure will facilitate a close check of new and unlisted conditions, rated by analogy. In the selection of code numbers, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. Thus, atrophic (rheumatoid) arthritis rated as ankylosis of the lumbar spine should be coded "5002-5289." In this way, the exact source of each rating can be easily identified. In the citation of disabilities on rating sheets, the diagnostic terminology will be that of the medical examiner, with no attempt to translate his terms into schedule nomenclature. Residuals of diseases or therapeutic procedures will not be cited without reference to the basic disease. The following ratings may be assigned under the conditions stated for disability from any disease or injury, in the absence of, or in lieu of, ratings prescribed elsewhere in the schedule for the disability. Injuries, recent, unhealed (specify Rating 100 Injuries, recent, unhealed (specify anatomical classification and nature of traumatism)—Con. Injuries, recent, unhealed, or improving, with definitely disabling manifestations as in this section but of lesser severity, such that resumption of partial employment is feasible and advised, for 6 months----Diseases, acute or subacute (specify anatomical and etiological classification): With continued infection, weakness, constitutional symptoms, limitation of physical activity, etc., necessitating hospitalization or such as to prevent the pursuit of a substantially gainful occupation on the part of the average person affected, for 6 months. Diseases, acute, subacute, or improving with definitely disabling manifestations as in this section but of lesser severity or improved so that resumption of partial employment is feasible and advised, for 6 months---- Rating 50 100 50 NOTE (1). The ratings in this section are applicable for a definite period, 6 months from date of discharge from the service: Provided, however, That the 100 percent rating, but not the 50 percent rating, may be extended upon examination near the expiration of this period disclosing persistence of disabling symptoms of active disease or unhealed injury, for a further period of 6 months only: Provided, further, That reduction or discontinuance of ratings authorized in this section will be in order prior to the expiration of the 6-month period, in the event reports of earlier examination or hospitalization disclose material improvement, absence of or recovery from the active disor injury. Reduction or discontinuance prior to the expiration of the 6-month period will be subject to the provisions of § 3.105(e) of this chapter but in no event will the ratings specified in this section be extended beyond the periods cited in this note. ease NOTE (2). Diagnosis of disease, injury, or residuals will be cited, with diagnostic code number assigned from this rating schedule for conditions listed. NOTE (3). Whenever the ratings in this section are applied the veteran will be specifically notified that his rating is for a limited period not to exceed 6 months, subject to reexamination. When at the end of the 6-month period (or at the end of the second 6-month period during which the total disability rating may be extended) a high degree of disability remains which cannot be adequately compensated under the rating schedule, reference will be made under § 3.321(b) of this chapter. |