What Do I Do If I Don’t Have Many Medical Records?
When you have filed your claim with the Department of Veterans Affairs, one of the first things they are going to do is review your medical records, including service records, VA Medical Center records, health records, and/or civilian health care records. If they do not quickly spot a direct link between the event in service and your current disability, your claim will most likely be denied.
Especially for veterans injured in combat, medical treatment notes may have not been recorded or available during your treatment. Some health information and records may have even been destroyed or lost. Fortunately, the VA has a requirement to view your disability according to the “at least as likely as not standard.” This means if there is a 51% probability that your injury or disability occurred during or was exacerbated during your period of service, the VA must service connect it. However, that does not mean it will be an easy or fast process.
While a paper trail is definitely helpful, it is still possible to win your claim without one. If you do not have a copy of your medical records, you can still be eligible for VA benefits.
How to File a VA Claim When You Have Minimal Medical Records
When you first file your VA claim, you will be scheduled for a C&P exam for a VA examiner to evaluate your conditions. For more tips on how to prepare for a C&P exam, check out some of our past blogs. If the examiner states that it is at least as likely as not that your condition began or worsened in service, great! The VA will most likely grant you service-connection. However, that isn’t always the case, or they may not fully express the extent and limitations of your condition.
It is extremely important for your case to obtain an independent medical opinion or independent medical exam (IMO/IME) from a board-certified doctor. Here at Hill & Ponton, we take care of the majority of this process for you. We will familiarize the doctor with your case and they will also complete their own personal review of your file. Depending on the circumstances of your case, you may need an in-office exam, videoconference or telephone conference. The doctor will then draft a report which details your medical history as well as their professional opinion in regards to your condition. If they believe there was an error in the C&P exam, such as an underqualified examiner, an incomplete exam, or any other oversight, they will speak to the C&P examiner’s opinion and state why they disagree. They will also conduct any necessary medical research pertaining to your conditions. Most importantly, they are familiar with the “at least as likely as not” standard. The doctors that we contract to do these IME/IMOs are highly qualified and we have long-standing relationships with many of them. These physicians share the same desire to help veterans.
Your attorney will review the completed report and if they find the evidence to be supportive, they will submit it to the VA. These IMEs/IMOs are key to winning your case.
Another helpful piece of evidence when you don’t have many medical records is personal statements from people in your life. Specifically, those you knew before you enlisted or those you served with. These “buddy statements” can be groundbreaking for your case. Outside perspectives can speak to how you were before service and how you are now, physically or mentally. You should ask any fellow veterans you are still in contact with who have witnessed or have first-hand knowledge of the incident that occurred in service if they would make a statement for your claim. Statements from family and friends are also greatly encouraged.
Winning a claim without many or any medical records is not easy, but it can be done. It will take patience and determination. Here at Hill& Ponton, we dedicate ourselves to explore all avenues to get a favorable outcome for your case.
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