General Medical Issues

As VA attorneys, we encounter daily the analysis of medical records submitted to VA in support of claims. Part of our job is to analyze the medical evidence that has been accumulated in a claims file to see whether a particular Regional Office (RO), the Board of Veterans Appeals (BVA), or even the Court of Appeals for Veterans Claims (CAVC) has overlooked or misinterpreted the medical evidence on record.

What Not to Do

Do not mail original medical records to the VA without keeping a copy for your own records. In addition, be sure to place your VA claim number on each page of evidence submitted to the VA. Unfortunately, like any large government entity, things can and will get lost. Your claims file may be shipped from a local RO to another RO if you move. It may also get shipped to Washington, D.C. if you appeal a rating decision to the BVA or appeal a BVA decision to the CAVC. Do not mail medical records to the VA and assume it will know what to do with them. The submission of medical records alone is insufficient to begin a claim. A letter requesting a claim form or indicating a desire to file a claim is the bare minimum that should be submitted along with medical records. Ideally, a VA claims form, which can be obtained from your local RO, or downloaded from this or the VA’s website, should be completed and submitted with supporting medical evidence.

What is Required by Law and Regulation

Medical evidence can be in the form of doctor or hospital treatment records, hospital summaries, including emergency room treatment, admission notes or discharge notes. A letter from a licensed nurse, psychologist, or other physician (even a chiropractor) is also helpful. Medical treatise information (such as that found on the internet) is only helpful if you have a medical professional discuss its applicability to you personally. All medical evidence should be clearly legible and dated. It should also involve the condition for which you seek compensation. In other words, don’t send the VA hospital treatment records for a tonsillectomy if you want service connection for a back disability.

Most importantly, if you obtain a letter from a health professional, make certain the letter indicates the condition for which you were evaluated and how that condition is related to your military service. Additionally, the doctor’s letter should address your symptoms and how your disability impacts your life. Keep in mind, the law requires three things:

Evidence of a current disability;

Medical or (in some instances) lay testimony of an incurrence of a disease, injury or condition in service; and

Medical evidence providing a link between the current disability and the disease, injury or condition noted in service stated in conclusive terms.

The Best Medical Evidence

Quite simply, the best medical evidence is obtained from private physicians. If at all possible seek treatment on a regular basis and make sure that treatment is well-documented. Obtain copies of your treatment records as soon as possible and keep them in a safe place. It often takes years to resolve a claim with the VA and records may be destroyed in the meantime. Keep in mind what your service medical records may or may not show. If you injured your back in service but never sought treatment, explain to your physician why treatment wasn’t sought. Inform your doctor of ongoing, continuous problems. If you ask the doctor for a letter explain to him what the letter must show (3 elements listed above – current disability, incident in service, medical link to service).

Explain that the doctor must state the reasoning for his or her opinion. The doctor should explain the nature and extent the examination, what objective evidence such as X-rays were reviewed and why any current disability is connected to your military service. Above all, the doctor’s opinion must be in clear and precise terms. Where a doctor states that a certain condition "may" or "could be" linked to service, VA is very quick to dismiss the opinion as "too speculative" to be given much probative weight. Rather your doctor should state that your disability is more likely than not related to the event in service.

Hopefully with these tips, you can obtain quality medical evidence in support of your claim that can then be submitted to VA for a more timely resolution of your case.