Secondary Conditions and VA Disability: The Hidden Path to Higher Ratings

Many veterans don't realize they can claim conditions that develop from their service-connected disabilities. These secondary conditions often lead to significant rating increases, sometimes adding 20-40 points or more to your overall rating.

If you have a service-connected disability, this guide shows you how to identify secondary conditions and claim them for rating increases.

What Are Secondary Conditions?

A secondary condition is a health condition that directly results from a service-connected disability. Unlike primary conditions that are directly service-connected, secondary conditions get their service connection through their relationship to an existing service-connected condition.

Key Principle: Medical Nexus

For a secondary condition to be awarded:

1. You must have a primary service-connected condition (already approved by VA)
2. The secondary condition must result from the primary condition (medical nexus)
3. The condition must be medically diagnosed (current diagnosis)

Real-World Examples

Knee surgery → Secondary conditions:

• Arthritis in knee (from wear-and-tear after surgery)
• Chronic pain syndrome
• Limitation of motion
• Swelling and instability

PTSD → Secondary conditions:

• Sleep apnea (from hypervigilance and tension during sleep)
• Hypertension (from chronic stress)
• Anxiety disorder
• Depression
• Insomnia

Agent Orange exposure → Secondary conditions:

• Type 2 diabetes (presumptive)
• Heart disease (from diabetes)
• Kidney disease (from diabetes)
• Neuropathy

Hearing loss → Secondary conditions:

• Tinnitus (often develops alongside hearing loss)
• Vertigo (balance issues from inner ear damage)
• Headaches

Combat-related back injury → Secondary conditions:

• Muscle weakness in legs
• Numbness/tingling in legs
• Sexual dysfunction (from nerve damage)
• Bowel/bladder issues

How Secondary Conditions Increase Your Rating

The Rating Formula

Your VA disability rating is calculated using the combined rating formula, which considers:

• Each service-connected condition's rating separately
• Their combined effect on your whole-person functioning

Why secondary conditions matter:

Adding a 20% secondary condition to your rating doesn't just add 20% to your total. It increases your whole-person efficiency rating, which can increase your overall rating by 5-10 percentage points or more.

Rating Increase Example

Veteran with 50% rated PTSD:

Without secondary conditions:

• PTSD: 50%
• Total rating: 50%
• Monthly pay: $1,092

Add secondary conditions:

• PTSD: 50%
• Sleep apnea: 30% (from PTSD hypervigilance)
• Headaches: 10% (from PTSD tension)
• Combined rating using VA formula: 68% (not 90%)
• Monthly pay: $1,549
• Monthly increase: $457/month = $5,484/year

Another example with higher ratings:

Veteran with 70% rated back injury:

Without secondary conditions:

• Back injury: 70%
• Total rating: 70%
• Monthly pay with spouse: $1,826

Add secondary conditions:

• Back injury: 70%
• Knee arthritis: 20% (from abnormal gait due to back injury)
• Muscle weakness: 10% (from back injury)
• Combined rating: 78% (rated as 80% in VA system)
• Monthly pay with spouse: $1,997
• Monthly increase: $171/month = $2,052/year

Identifying Potential Secondary Conditions

Ask yourself about each service-connected condition:

For Physical Conditions (PTSD, Traumatic Brain Injury, Burn Injuries, etc.)

Could this condition cause:

• Sleep disturbances? (Sleep apnea, insomnia)
• Pain in other areas? (Pain syndrome, neuropathy)
• Weakness or limitation? (Muscle weakness, reduced mobility)
• Inflammatory responses? (Arthritis, swelling)
• Psychological effects? (Anxiety, depression from chronic pain)
• Digestive issues? (IBS, GERD from stress/pain)
• Sexual dysfunction? (From nerve damage or medication)
• Headaches? (From tension or nerve damage)

For Mental Health Conditions (PTSD, Depression, Anxiety)

Could this condition cause:

• Sleep problems? (Sleep apnea, insomnia)
• Heart issues? (Hypertension, irregular heartbeat from stress)
• Immune issues? (Frequent infections from stress)
• Digestive problems? (IBS, ulcers)
• Substance abuse? (Trying to self-medicate)
• Accidents/injuries? (From poor judgment or recklessness)
• Muscle tension? (Chronic tension headaches, neck pain)

For Sensory Conditions (Hearing Loss, Vision Loss)

Could this condition cause:

• Balance problems? (Vertigo, falls)
• Headaches? (Eye strain, tension from compensation)
• Psychological distress? (Depression from isolation)
• Tinnitus? (Often develops with hearing loss)

How to Get a Nexus Letter for Secondary Conditions

The VA often denies secondary conditions because the medical opinion connecting them to your service-connected condition isn't clear enough. This is where a nexus letter becomes critical.

What Is a Nexus Letter?

A nexus letter is a medical opinion stating that your secondary condition is related to your service-connected condition. It's written by a medical doctor (MD, DO, PA, NP, or psychologist) and specifically addresses whether your secondary condition is caused by your primary condition.

Elements of a Strong Nexus Letter

A strong nexus letter includes:

1. Clear diagnosis: Specific diagnosis of the secondary condition (not vague)
2. Medical certainty: "More likely than not" or "at least as likely as not" that the conditions are related
3. Mechanistic explanation: How the primary condition causes the secondary condition (the "why")
4. Timeline: When the secondary condition started relative to the primary condition
5. Medical literature reference: Citing established medical knowledge about the relationship
6. Exclusion of other causes: Addressing whether other factors could cause the secondary condition

Weak vs. Strong Nexus Letters

Weak nexus letter:

"The veteran has PTSD and sleep apnea. These conditions may be related."

• Too vague
• "May be related" isn't strong enough
• No mechanistic explanation

Strong nexus letter:

"The veteran has a 50% rated PTSD diagnosis characterized by hypervigilance and nightmares. Based on current medical literature, chronic hypervigilance causes sleep fragmentation and can lead to sleep apnea development. The veteran's sleep apnea diagnosis in [date] occurred [X] years after PTSD onset, consistent with a causative relationship. The veteran has no other significant risk factors for sleep apnea (non-smoker, normal BMI, no other relevant conditions). It is at least as likely as not that the veteran's sleep apnea is caused by or materially worsened by the service-connected PTSD."

• Specific diagnosis
• Clear standard of certainty
• Explains the mechanism
• Acknowledges timeline
• References medical knowledge
• Addresses alternative causes

Filing a Secondary Condition Claim

Step 1: Identify Your Service-Connected Condition

You can only claim secondary conditions from a condition that's already service-connected. Check your current VA rating to see your service-connected conditions.

If you don't know:

• Log into VA.gov
• Check your rating decision letter
• Contact VA at 1-800-827-1000

Step 2: Identify Potential Secondary Conditions

List conditions you currently have that might be related to your service-connected disability. Think about:

• Conditions that developed after your primary condition
• Conditions that your doctor says are related to your service-connected condition
• Conditions that have worsened because of your primary condition

Step 3: Gather Medical Evidence

Collect any medical records showing:

• Current diagnosis of the secondary condition
• When the secondary condition was diagnosed
• Treatment received for the secondary condition
• Any medical provider statements about the relationship

Step 4: Obtain a Nexus Letter (Highly Recommended)

This is critical. Schedule an appointment with a medical provider and request a nexus letter specifically addressing whether your secondary condition is caused by or related to your service-connected condition.

Where to get a nexus letter:

• Your VA doctor: Free, but VA doctors are sometimes reluctant to write nexus letters
• Private doctor: More favorable to veterans, costs $300-$800 typically
• Nexus letter services: Provide vetted doctors, costs $400-$1,200

Step 5: Complete VA Form 21-526EZ (or 21-0960, depending on your situation)

File a claim for the secondary condition. In the form, explain:

• Which service-connected condition caused this secondary condition
• What evidence you have of the relationship
• Include your nexus letter with the claim

Step 6: Submit Your Claim

Submit online at VA.gov (fastest), by mail, or in person at your VA regional office.

VA Rating Schedule for Secondary Conditions

The VA rates secondary conditions using the same rating schedule as primary conditions. For example:

Sleep apnea ratings:

• 0% - Documented sleep apnea without significant daytime symptoms
• 10% - Documented sleep apnea with some daytime sleepiness
• 20% - Documented sleep apnea with moderate daytime sleepiness affecting functioning
• 30% - Documented sleep apnea with significant daytime sleepiness affecting ability to work

Headaches/migraines:

• 0% - Infrequent (averaging less than once per month)
• 10% - Frequent (averaging 2-4 per month) without aura
• 20% - Frequent with aura, or very frequent without aura

The same rating criteria apply whether it's a primary or secondary condition. The difference is just in how service connection is established.

Common Secondary Condition Scenarios

PTSD Secondary Conditions

Veterans with PTSD frequently develop:

• Sleep apnea (30% common rate): From nightmares, hypervigilance, sleep fragmentation
• Insomnia (10-20% typical): From hyperarousal
• Hypertension (10-20% typical): From chronic stress
• Anxiety disorder (10-20% typical): Co-occurring with PTSD
• Depression (20-30% typical): Depression often accompanies PTSD
• Migraine headaches (10-20% typical): From tension and stress

Hearing Loss Secondary Conditions

Veterans with hearing loss often develop:

• Tinnitus (10-20% typical): Direct relationship to hearing loss
• Vertigo/balance issues (10-20% typical): From inner ear damage

Agent Orange Secondary Conditions

Veterans exposed to Agent Orange with presumptive conditions:

• Service-connected to Type 2 Diabetes
• Then develop Heart disease (secondary to diabetes)
• Then develop Kidney disease (secondary to diabetes)
• Then develop Neuropathy (secondary to diabetes)

Each condition can be rated, potentially reaching 70%+ combined rating.

Back Injury Secondary Conditions

Veterans with back injuries frequently develop:

• Leg pain/neuropathy (10-20%): From nerve compression
• Muscle weakness (10%): From nerve damage
• Arthritis in knees/hips (10-20%): From abnormal gait compensation

Common Secondary Condition Mistakes

1. Not pursuing secondary conditions: Veterans are eligible but don't claim them
2. Weak nexus letters: No nexus letter or a poorly written one without clear mechanism
3. Filing before diagnosis: Claiming a secondary condition before it's officially diagnosed
4. Not gathering sufficient evidence: Missing medical records showing the relationship
5. Assuming VA will make the connection: VA won't connect conditions on your behalf—you must do it

Secondary Condition Appeal Success Tips

If secondary condition claim is denied:

• File a Supplemental Claim with a stronger nexus letter
• Request a Higher-Level Review if VA misinterpreted medical evidence
• Have a Board Appeal if you have strong medical support

Success rates for secondary conditions are generally 60-70% if you have adequate medical documentation and a solid nexus letter.

Key Takeaways

• Secondary conditions can result from service-connected disabilities
• Medical nexus (causal relationship) is required
• A strong nexus letter is critical—worth the expense ($300-$1,200)
• Secondary conditions use same rating schedules as primary conditions
• Can significantly increase your overall rating and monthly benefits
• Each secondary condition adds to your combined rating
• File all potential secondary conditions—don't assume VA will notice them
• Common secondary conditions from PTSD: sleep apnea, hypertension, depression
• Common secondary conditions from physical injuries: arthritis, muscle weakness, nerve pain
• If denied, appeal with stronger medical documentation