VA Form 4107INS Your Rights to Appeal Our Decision

What Is VA Form 4107INS?

VA Form 4107INS, Your Rights to Appeal our Decision is a document used by veterans to appeal against the Department of Veterans Affairs (VA) decision to deny an insurance claim.

In accordance with Form 4107INS VA, a veteran can choose to have representation. A list of Veterans Service Organizations to represent veterans' interests for free can be found online on the VA website. Additionally, an «agent» or an attorney can represent the veteran, although these services may not be free of charge.

VA decision appeal form states a veteran has one year to appeal to the Board of Veterans' Appeals with the help of a Notice of Disagreement, or six years to challenge the VA's decision by lodging a complaint with a district court.

The latest version of VA 4107INS Form was released by the VA in May 2017 with all previous editions obsolete. A printable VA Form 4107INS fillable version is available for download or can be found through the VA website.

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YOUR RIGHTS TO APPEAL OUR DECISION
We have reached a decision on your application or claim. This form will tell you what to do if you disagree with
our decision.
IF YOU DISAGREE WITH OUR DECISION
If you disagree with our decision, you can:
1. Submit New Evidence to Support Your Claim
You can send any additional evidence you have to support your application or claim to the address at the
top of our letter. We will consider any new evidence as long as it is evidence we have not already seen and
it relates to your claim. We will then let you know whether it changes our decision.
2. Appeal
If you want to begin an appeal of our decision, you must:
a. Write us a letter telling us you disagree with our decision. This letter is called your "Notice of
Disagreement." If we denied applications or claims for different insurance policies, please tell us in
your letter which insurance policy or policies your disagreement concerns. You can also send us
additional evidence with your Notice of Disagreement.
b. Send your Notice of Disagreement and any additional evidence to support your application or claim
to the address at the top of our letter.
We will review your Notice of Disagreement and any new evidence together with the evidence we already have
and let you know whether it changes our decision. If we cannot approve your application or claim, we will send
you a letter notifying you of our decision and asking if you want to continue your appeal or withdraw it. If you
choose to continue your appeal, we will send you a Statement of the Case that describes the facts, laws,
regulations, and reasons we used to make our decision and a VA Form 9, "Appeal to Board of Veterans' Appeals"
to complete.
3. Challenge VA's Decision at a Federal Court
You may also challenge VA's decision on your application or claim by filing a complaint with a United
States district court in the District of Columbia or in the district in which you reside within six years from
when the right of action first accrues. To find a district court, use the map on this website:
http://www.uscourts.gov/court_locator.aspx.
HOW LONG DO I HAVE TO APPEAL THE DECISION?
You have:
• One year to appeal to the Board of Veterans' Appeals (Board) by submitting a Notice of Disagreement; or
• Six years to challenge VA's decision at a federal district court.
If you do not start your appeal on time, our decision will become final. Once our decision is final, you cannot get
the VA benefit we denied unless you either show that we were clearly wrong to deny the benefit or send us new
evidence that relates to the reason we denied your claim.
YOUR RIGHT TO REPRESENTATION
You can have someone represent you, if you wish. You can find a list of Veterans Service Organizations that will
represent you for free at http://www.va.gov/vso. An attorney or agent can also represent you but may require you
to pay for their services. VA cannot pay any attorney or agent fees.
VA FORM
4107INS
MAY 2017
YOUR RIGHTS TO APPEAL OUR DECISION
We have reached a decision on your application or claim. This form will tell you what to do if you disagree with
our decision.
IF YOU DISAGREE WITH OUR DECISION
If you disagree with our decision, you can:
1. Submit New Evidence to Support Your Claim
You can send any additional evidence you have to support your application or claim to the address at the
top of our letter. We will consider any new evidence as long as it is evidence we have not already seen and
it relates to your claim. We will then let you know whether it changes our decision.
2. Appeal
If you want to begin an appeal of our decision, you must:
a. Write us a letter telling us you disagree with our decision. This letter is called your "Notice of
Disagreement." If we denied applications or claims for different insurance policies, please tell us in
your letter which insurance policy or policies your disagreement concerns. You can also send us
additional evidence with your Notice of Disagreement.
b. Send your Notice of Disagreement and any additional evidence to support your application or claim
to the address at the top of our letter.
We will review your Notice of Disagreement and any new evidence together with the evidence we already have
and let you know whether it changes our decision. If we cannot approve your application or claim, we will send
you a letter notifying you of our decision and asking if you want to continue your appeal or withdraw it. If you
choose to continue your appeal, we will send you a Statement of the Case that describes the facts, laws,
regulations, and reasons we used to make our decision and a VA Form 9, "Appeal to Board of Veterans' Appeals"
to complete.
3. Challenge VA's Decision at a Federal Court
You may also challenge VA's decision on your application or claim by filing a complaint with a United
States district court in the District of Columbia or in the district in which you reside within six years from
when the right of action first accrues. To find a district court, use the map on this website:
http://www.uscourts.gov/court_locator.aspx.
HOW LONG DO I HAVE TO APPEAL THE DECISION?
You have:
• One year to appeal to the Board of Veterans' Appeals (Board) by submitting a Notice of Disagreement; or
• Six years to challenge VA's decision at a federal district court.
If you do not start your appeal on time, our decision will become final. Once our decision is final, you cannot get
the VA benefit we denied unless you either show that we were clearly wrong to deny the benefit or send us new
evidence that relates to the reason we denied your claim.
YOUR RIGHT TO REPRESENTATION
You can have someone represent you, if you wish. You can find a list of Veterans Service Organizations that will
represent you for free at http://www.va.gov/vso. An attorney or agent can also represent you but may require you
to pay for their services. VA cannot pay any attorney or agent fees.
VA FORM
4107INS
MAY 2017

Download VA Form 4107INS Your Rights to Appeal Our Decision

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Your Rights to Appeal Our Decision

According to the VA appeal form, there are three possible routes to take if a veteran disagrees with a decision:

  • Submitting new evidence in support of the claim. A veteran has a right to send any supplementary evidence to support the application or claim to the address given in the VA letter. Once the evidence has been received, the VA lets a veteran know whether it changes the initial decision;
  • Appealing. To commence this process, a veteran must write a letter informing the VA about disagreeing with the decision. This letter is called a Notice of Disagreement. It is possible to send additional evidence with the Notice to the address given in the VA letter. The VA will review the documents and will let the veteran know whether a new decision has been made. If an application or a claim cannot be approved, the VA will send a letter notifying the veteran of this decision and asking if the veteran wants to continue the appeal or withdraw it. In the former case, the VA sends the veteran a Statement of the Case that describes the facts, reasons, laws, and regulations they used to make a decision and a VA Form 9, Appeal to Board of Veterans' Appeals;
  • Challenging the VA's decision at the federal court. A veteran is eligible to file a complaint in the United States District Court.

VA Appeal Form 4107 Series

The Department of Veterans Affairs VA Form 4107INS has four other related forms: