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Monday, May 23, 2016

Supporting Documents—The Key to a Successful VA Disability Claim

I’ve stressed numerous times throughout this blog just how important supporting documents are when submitting a VA Disability Claim.

No evidence = a denied claim. Period.

To ensure that your claim is successful, compiling and submitting the necessary supporting documents is essential.

There are different kinds of supporting documents; some everyone will need, while others are only needed in special cases.

Here is a list of some of the most common supporting documents needed for a VA Disability Claim:

     - Service Treatment Records (STRs)
     - Civilian Medical Records
     - VA Medical Documents
     - DoD Disability Documents (MEB and PEB decision docs)
     - Military Personnel Records (deployment orders, exposure documentation, separation docs, etc.)
     - Other documents that support your case

Service Treatment Records:

Everyone needs to submit their service treatment records. No exception. The number one way to prove service-connection (a requirement all conditions must meet to be eligible for VA Disability) is to provide medical records that show that the condition existed while you were in the military. Just saying you had the condition when you were in the military but just never went to the doctor is not enough. You have to have proof. No proof = no service-connection.

This is also why I encourage service members to get examined for every condition they have, even if it isn’t a big deal at the time. If it worsens in the future, as long as it can be found in the service treatment records, it will qualify for VA Disability.

There are, of course, other ways to prove service-connection, but they are much more tricky. By far, the easiest is service treatment records.

Civilian Medical Records:

If you have gone to a civilian medical provider for treatment separate from the DoD and VA health systems for the conditions you are claiming, then you need to submit those medical records along with your claim. The VA needs to see all the evidence you have regarding your condition.

Now if it was a referral, then those records should already be on file, but double check just to make sure that the VA does have everything. The VA’s getting better at requesting and acquiring records, but it’s still far from flawless. And, besides, you want to keep a copy of everything in your own records anyway, so getting your own copy is always good.

VA Medical Documents:

Although the VA looks at and uses all submitted evidence to rate conditions, the VA’s C&P Exams are directly designed for rating purposes, so they are very important. These medical records will already be in the system, but it is a good idea to get copies for yourself in case there is ever a hitch in the system. Plus having them on hand will make it easier for you to build a strong appeals case, if needed.

DoD Disability Documents:

If you were medically separated from the military, then you’ll have gone through the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB), so you’ll need to submit all documents pertaining to their decisions to the VA. Make sure to include supporting documents you submitted to the Boards, like your commander’s letter, other testimonies, etc. Pretty much anything the Boards needed, the VA will need.

Now if you were separated between 2009 and the present, then you’ll have gone through the IDES and the VA will already have all of these since the IDES combines the DoD and VA disability processes. Again, keep a copy in your records and check to make sure they have everything.

Military Personnel Records:

Military personnel records are other duty records, like deployment orders, exposure documentation, and separation docs that provide evidence on aspects of your military service that is important for VA Disability purposes.

Everyone needs to submit their separation/discharge docs (DD Form 214, and the like) because your date of separation directly impacts when the VA should start providing compensation.

The majority of other military personnel records should only be submitted in special circumstances. These are used mainly to prove service-connection for conditions that develop after discharge but were caused by circumstances in your military career.

For example, if you were deployed to Vietnam and exposed to Agent Orange between 1962 and 1975, and now have a condition on the VA Presumptive List, you need to submit your deployment records in order to prove that you were deployed to Vietnam during the right time frame. Otherwise, the condition will not be approved.

Similarly, if you were exposed to radiation, you’ll need to submit the documents that clearly outline the details of your exposure.

Do not, however, submit all of your military personnel records. No one cares if you were stationed in Boise. Only submit ones that directly support your case.

Other Documents:

If you have any additional documents that support your case make sure to submit them, but be smart. Do not just submit a random document unless it is truly pertinent to your case. You want to make the Rating Authority’s job easier, so extraneous paper is never a good idea.



Now that you know what documents you need to submit with your VA Disability Claim, let’s talk about how to get them all.

In most cases, the VA should keep digital records of the majority of your documents, including your military personnel file and other service documents. Before trying anything else, log in to your eBenefits account and see what you can access from there. Your VA Medical Documents will definitely be there. Most of the rest should be there too, especially if you separated more recently. This document gives step-by-step instructions on how to find these docs within the eBenefits portal: eBenefits Records.

Now if you couldn’t find everything you needed through eBenefits, there are other options.

Service Treatment Records are kept at the medical facility where you were last stationed for up to a year after separation. They are then sent to an archive facility. Contact the medical record department at your last medical facility. If they still have them, you can request a copy straight from them. If not, they can tell you where they sent them to be archived. You can also check out archives.gov, although their website isn’t terribly user-friendly.

To get your Civilian Medical Records, just contact your civilian doctor/facility directly.

DoD Disability Documents are a part of your Military Personnel Record, so you should be able to get both from the same place.

Click the following link to take you to information on how to access your records:

     Air Force
     Army  (Note on this one: it’s a third party site, but a comprehensive list too long to 
        reproduce here. Army always has to be more complicated…)
     Coast Guard
     Marines
     Navy

At some point, records are all sent to the Custodians of each branch, so for older records, check the Custodian List for contact information.

10 comments:

  1. Thanks Dr. Johnson! Your knowledge and assistance is much appreciated.

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  2. Dr. Johnson, "History of" vs. Diagnosis; I am facing a semantic nightmare. The PEB is denying one of my MEB-found unfitting conditions because it says "History of" and not Diagnosis. This is because I had to wait four months to get back to the states for definitive specialty consultation and care. I am facing not being able to retire with benefits, because the PEB is playing word games. The documentation is clear that I had an MI, but the PEB is trying to pull a fast one. I would love some advise, before I have to face the Formal PEB, date pending.

    ReplyDelete
    Replies
    1. Do you have the date of the myocardial infarction clearly documented? What happened right after the heart attack? What treatment did you receive? As long as your medical records show that you had a heart attack while on active duty, then that counts as the diagnosis. A heart attack is a heart attack. If it occurred, it occurred. Do you have any documentation of the original incidence? For the consultation with the specialist, they are saying that you have a "history of MI", correct? Does the record include a date of the incident? I recommend going back to the specialist and having him write up a more thorough history clearly outlining the dates and full history of the MI.

      As long as you can show that the MI did happen while on active duty, that's all you need. Even the VASRD states that that is enough to prove service-connection. Check out the discussion for code 7006 for myocardial infarctions:

      http://www.militarydisabilitymadeeasy.com/theheart.html#d

      Now it is also important to note that just because you had a heart attack doesn't mean that you have any lasting symptoms that cause a current disability. The PEB gives ratings for a condition's severity at the time of separation, so if the MI didn't cause any lasting symptoms, you may not get a rating higher than 0%, even if proven service-connected. To get even a 10% rating for a heart condition, you have to score an 8-10 MET with fatigue, chest pain, dizziness, etc., or you have to take continuous medication. If you don't have these symptoms or take medication constantly, then you won't get a rating higher than 0%.

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    2. I've been on continuous medication for over a year; medication that is given to those that have suffered a heart attack. I'm still on that medication. The C&P examiner failed to annotate the MI. The MEB/PEB both acknowledged the history of MI. The VA failed to rate it, even though I provided documentation. Four unfitting conditions were sent to the VA they combined two into one A-Fib with history of MI and rated it 10%, using code 7010. MI should have been rated independent of A-Fib, code 7006. And rated at least 10% for the fact that I am on continuous meds. I plan on addressing in my VARR. I just don't know best to do it. The VA provider also failed to follow the explicit instructions on what medications I am taking what it is for (i.e. lisinopril for high blood pressure; Hydrochlorothiazide for high blood pressure; Metoprolol for Myocardial Infarction; Indomethinicin for Ankylosing Spndylitis) all of which I have been taking for over a year. I had to wait four months from returning from over seas to get my MI identified by a cardiologist; he explicitly wrote why he believed I suffered and survived an MI in his notes. The cardiologist (and two other cardiologists, independently agreed with the continuation of meds) agreed with the medications, continued. There is other physical evidence, dizziness, edema after the 16 hour flight from overseas. Edema has gone away but dizziness continues intermittently.

      I have other information I'd like to share with you, privately.

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    3. I forgot to add another medication I've been taking for over a year, Xarelto for A-Fib.

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    4. It sounds like the VA, not the PEB made the real error in your case. If the VA doesn't rate something, then the PEB won't either. The PEB uses the VA's ratings. So, what you really need to do is appeal the VA's decision and get that fixed first. Then you won't have any problems with the PEB. If you want to contact us privately, use our contact form on our website.

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  3. How do I overcome the loss of a medical record that could undoubtedly prove service connectivity? I'm experiencing that with my neck. Thanks!

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    Replies
    1. The medical record was a month long therapy session at Eglin AFB where they treated a problem with my neck. That record did not make it to my file. I have a claim in with archives.gov. What if I do no find the record?

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    2. Hi Vince -

      Bad news. No record = no benefits. This is an all-too-common problem that many veterans face, but there isn't anything you can do about it. The law that requires proof of connection is good in that it protects the system from those that would abuse it, but in situations like yours, it can also cause problems. And there simply isn't a fix.

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  4. Thank you. I will heed the sound advise.

    ReplyDelete