Developing Medical Evidence to Support A Claim

Posted by Gregory M. Rada | April 12, 2022 | Disability Compensation, Health Benefits

One of the most important factors in winning a claim or appeal for VA disability compensation benefits is developing medical evidence in support of your case. There is virtually no way to get your disability claim approved without sufficient medical evidence to support your claim. In this post, I put together some tips about developing medical evidence in support of your VA claim or appeal.

Important Tips in Developing Your Medical Evidence

Every case is different, but I recommend the following general tips to help you develop the evidence needed to win your case:

• Report all your symptoms to your doctors (military, VA, or private doctors) each time you visit. This will ensure that all your symptoms are well-documented in your medical records.
• Obtain medical treatment often. While frequent visits to the doctor may seem repetitive and unnecessary, they help establish that your disability is chronic and ongoing, which is one of the requirements for service connection.
• Undergo all recommended objective and diagnostic testing. This is important because the VA cannot ignore objective diagnostic findings.
• Follow your doctor’s treatment recommendations. If the VA sees you aren’t following recommended treatments, they might assume your disability isn’t so bad.
• Keep a record of your doctor’s appointments, medications, and any side effects. This will ensure that every bit of relevant medical evidence is obtained.

Developing the Medical Evidence to Support Your VA Claim

Consider the following steps to boost your chances of winning your VA disability compensation claim.

1. Gather All Your Military, VA, and Private Medical Records

Make every effort to collect all military, private, and VA medical records and make sure they are submitted to VA in support of your claim.

Military Medical Records

As a general rule of thumb, when you file a claim, the VA will obtain and associate with your claims file all your military medical records. You can make sure the VA has all your service treatment records by obtaining a copy of your claims file and a copy of your military records. You can request a copy of your VA claims file by calling VA at 1-800-827-1000 and you can obtain a copy of your military records by completing and submitting an SF-180 form.

Knowing what’s in your service treatment records can help you craft a claim for VA disability benefits that has a higher chance of being granted.

VA Medical Records

Again, the VA will automatically obtain all your VA treatment records when you file a new claim, as long as you tell the VA at which medical centers you received treatment.

If you want your own copy, you can obtain it from  the VA medical center where you receive treatment or you can download an electronic copy from an online VA portal known as MyHealtheVet.

Private Medical Records

If you are receiving private medical treatment that relates to the medical condition for which you are seeking service connection, then you are going to want to give those records to VA.

You can obtain private treatment records by requesting them from your private healthcare provider, and many private providers also have online portals from which you can download the records.

Alternatively, you can complete and submit a VA Form 21-4142 to the VA, which is a medical release form that gives the VA permission to obtain your private treatment records. Be advised that the VA won’t pay private providers for treatment records, so if your provider won’t give them for free to the VA, then you will have to obtain the records yourself.

Finally, if your private doctor believes your disability is related to service, have them write so in your medical record. They need to use the language that it’s “at least as likely as not” that the disability is related to the military, and then provide a short explanation as to why they believe that.

2. Attend Your Compensation and Pension (C&P) Exams

Compensation and Pension (C&P) examinations are crucial for any VA disability claim. As long as there is a reasonable chance that your claimed disability is related to the military, the VA will schedule you for a C&P examination. There, the VA examiner were diagnose you, describe the severity of your disability, and give an opinion as to whether it is at least as likely as not that your disability is related to military service.

3. Obtain Buddy Statements and Lay Statements

Obtain written statements from anyone who knows you and your conditions. Buddies may include your co-workers, friends, spouse, parents, people you served with, or your children. In these statements, your buddies can explain how the disability affects you (for instance, it’s difficult to hear, squat, or bend). A good buddy statement will describe how you were injured or what symptoms they witness.

Finally, you can write your own written statements, also called lay statements. Lay statements can be extremely valuable, and they are way for you to get directly into the record what you are experiencing in your own words. Oftentimes, VA examiners will not put into the record everything you tell them, so a lay statement is a good way to protect against that.

4. Hire an Attorney to Obtain an Independent Medical Opinion

It is often necessary to get an independent medical opinion in order to win your appeal for service connection. A good attorney will work with reputable medical experts to draft a favorable nexus opinion. For the VA to accept the independent opinion, the expert must state that they reviewed the relevant records from the VA claims file, and they must provide clear rationale, with citations to the record, as to why the disability is related to military service.

Frequently Asked Questions on Developing Medical Evidence

How Do I Show the Nexus (Relationship) Between My Active Service and My Disability?

Sometimes it is not easy to show the connection between your active service and a disability because the issue is complex or because the VA examiner isn’t uptodate on medical science. In such cases, you need to obtain an independent medical opinion (IMO). One of my main tasks as a VA disability attorney is working with medical experts to draft a nexus opinion that is well-supported by the record and medical science.

What is the Duty to Assist?

The term Duty to Assist refers to the U.S Department of Veteran Affairs’ obligation to help you develop your claims. The Duty to Assist requires VA to help you collect evidence and information to prove service connection, including obtaining your medical records and providing you with a C&P examination and nexus opinion.