The VA is taking away my insomnia rating - why? What can I do?

by Deborah Miller, PhD, HSPP - owner and lead psychologist at vetnexusletter.com

I've been hearing from many veterans who are receiving VA letters stating that their service-connected insomnia is being combined, merged, or folded into the rating for the primary physical condition that caused it. For example, a veteran may have been service connected for tinnitus at 10%, and insomnia secondary to tinnitus at 50%, but the VA is now calling it "tinnitus with insomnia" as one condition, and because tinnitus is rated at a maximum of 10%, VA may now treat the combined condition as only a 10% rating total.

This is understandably frustrating. In many cases, the insomnia far more disabling than the tinnitus, knee pain, back pain, or other physical condition that originally triggered it. Chronic insomnia can cause serious problems with mood, concentration, memory, irritability, work performance, relationships, and daily functioning. Clinically, it may be much more impairing than the original physical condition. However, VA’s current approach often treats insomnia differently than veterans expect.

Why is VA doing this?

VA generally considers insomnia to be a symptom of another condition when it is caused by a physical or mental health disability. Under VA’s current guidance, if insomnia is identified as secondary to another disability, such as tinnitus, chronic pain, sleep apnea, or a mental health condition, the VA may decide that insomnia should be evaluated as part of that underlying condition rather than assigned a separate rating.

VA relies heavily on the rule against “pyramiding,” which means VA is not supposed to compensate the same symptom twice under different diagnoses. Under 38 CFR § 4.14, VA must avoid rating the same disability manifestations under multiple diagnostic codes.

This creates a major problem when the underlying condition has a low maximum rating. Tinnitus, for example, is rated at 10% maximum under Diagnostic Code 6260, regardless of whether it is in one ear, both ears, or the head.  So if VA folds insomnia into tinnitus, the veteran may be left with a 10% rating even though the insomnia causes significant impairment.

Has the law changed?

Not exactly.

There does not appear to be a simple new regulation saying, “Insomnia secondary to tinnitus can no longer be separately rated.” Instead, VA appears to be applying its internal guidance more strictly. The practical effect is that many veterans who previously received, or expected to receive, a separate rating for insomnia secondary to tinnitus, pain, or another condition are now seeing VA merge the insomnia into the primary condition.

VA does still recognize secondary service connection. Under 38 CFR § 3.310, a disability that is proximately due to or aggravated by a service-connected condition may itself be service connected.  The issue is not whether secondary conditions exist. They do. The issue is whether VA views “insomnia” as a separately ratable disability or as a symptom of something else.

Why this matters for veterans

This matters because “insomnia secondary to tinnitus” may not fully capture what is actually happening clinically.

A veteran may begin having sleep problems because of tinnitus, back pain, knee pain, migraines, or another service-connected condition. Over time, the chronic sleep disruption may contribute to or worsen:

• Depression

• Anxiety

• Irritability

• Panic symptoms

• Social withdrawal

• Low motivation

• Poor concentration

• Reduced work reliability

• Relationship strain

• Emotional dysregulation

In those cases, the veteran may not simply have “insomnia.” The veteran may have a separate mental health condition like depression, anxiety, or adjustment disorder caused or aggravated by the service-connected physical condition and the chronic sleep disruption. This would be considered a separate disorder which could then be rated separately from and secondary to the original physical condition/insomnia.

The better claim strategy: look beyond insomnia alone

If VA merges a veteran’s insomnia into tinnitus, knee pain, back pain, or another primary physical condition, the veteran should consider whether they also have a diagnosable mental health condition related to that same primary disability.

For example:

A veteran has service-connected tinnitus. The tinnitus causes chronic sleep disruption. Over time, the veteran develops anxiety, depressed mood, irritability, concentration problems, and social withdrawal. VA may refuse to separately rate “insomnia secondary to tinnitus,” but the veteran may still be able to pursue a claim for:

Anxiety disorder secondary to service-connected tinnitus and chronic sleep impairment

or

Depressive disorder secondary to service-connected tinnitus and chronic sleep impairment

or

Adjustment disorder with anxiety and depressed mood secondary to service-connected tinnitus and chronic insomnia

The same logic may apply to veterans with chronic pain conditions. A veteran with service-connected back pain or knee pain may develop insomnia because pain keeps them awake. But if the sleep disruption and chronic pain also lead to depression, anxiety, reduced motivation, irritability, and difficulty functioning, then a secondary mental health evaluation may be appropriate.

VA rates most mental health conditions under the General Rating Formula for Mental Disorders, with ratings based on occupational and social impairment. Mental health ratings can be assigned at 0%, 10%, 30%, 50%, 70%, or 100%, depending on severity, and will be in addition to the percentage rating of the primary condition/insomnia.

What veterans should do

Veterans who receive a VA letter merging insomnia into another condition should not panic, but they should read the letter carefully. It is important to determine whether VA is proposing a reduction, severing a prior rating, correcting an alleged error, or simply explaining how a new claim was evaluated.

Veterans should also consider getting evaluated for mental health symptoms that may have developed because of the service-connected physical condition and chronic sleep impairment. The key question is not only, “Do I have insomnia?” The better question is:

Has my service-connected condition and resulting sleep impairment caused or aggravated a mental health condition?

A strong evaluation should address:

• The original service-connected condition

• How that condition disrupted sleep

• How long the sleep disruption has persisted

• Whether the veteran developed anxiety, depression, adjustment problems, irritability, or other psychiatric symptoms as a result of the primary condition and resulting sleep disturbances

• How those symptoms affect work, relationships, daily functioning, and quality of life

  
  

The important takeaway

VA may now be more likely to merge insomnia into the primary physical condition that caused it, especially when insomnia is claimed as secondary to tinnitus, pain, or another already service-connected disability. This can result in unfairly low ratings when the primary condition has a limited rating schedule, such as tinnitus at 10%.

But that does not mean veterans are out of options.

If the insomnia has contributed to a broader mental health condition, such as anxiety, depression, adjustment disorder, or another diagnosable psychiatric disorder, the veteran may be able to pursue a separate secondary mental health rating. That separate rating may better reflect the true level of impairment caused by the combined effects of the physical condition and chronic sleep disruption.

In many cases, the best path forward is not to fight only for “insomnia secondary to tinnitus” or “insomnia secondary to pain.” The stronger path may be a full mental health evaluation that looks at whether the veteran has developed a secondary psychiatric condition as a result of the service-connected condition and the chronic insomnia it caused.

I've never been diagnosed with a mental health disorder. How can I start this process?

If the VA has already merged your insomnia rating with the primary condition, or they are threatening to, then now is the time to seek evaluation for additional mental health disorders related to your service-connected conditions. It is OK if you have not done this yet. You can pursue this in several ways:

• Reflect on your moods, anxiety, irritability, social relationships, enjoyment in life - have any of these things been affected by your physical disability and/or resulting sleep disruption?

• Ask family members and friends if they have noticed any changes in you based on your physical conditons and sleep habits - it might be helpful for them to write a statement of support if you decide to submit a claim for mental health.

• Discuss your symptoms with your primary care physician, making sure to detail how your symptoms are related to your physical conditions and sleep. Ensure that your physician documents this in your records and provides treatment options, including referral to therapy and/or medication (if you are interested, but this is not required and is a personal decision).

• Seek evaluation with an independent examiner who is experienced in documenting mental health conditions that result from service-related disabilities. The can provide you with a mental health diagnosis and a "nexus" that connects your current mental health directly to your disability and sleep impairment - this type of evidence can strongly support your claim, but is not always necessary if your other medical documentation and lay statements are strong.

If you are interested in pursuing an independent evaluation, Dr. Miller can help. As a former C&P examiner for the VA, she is experienced in providing the type of evaluations and documentation to support your claim. Fill out her information form to get started.