Letters to Medical Experts

1. Letters to Medical Experts 2007 NVLSP

2. Steps to Take Before Seeking a Medical Opinion • Obtain a current diagnosis; • Submit evidence that shows it is possible (even better “as likely as not” or “more likely than not”) that the alleged in-service incident or event occurred; • Research the current condition; • Interview the claimant/veteran and help the claimant prepare a statement detailing the symptoms noted by the veteran that the advocate and the veteran believe are related to the current disability; • Interview family members and friends of the veteran who can provide additional lay statements regarding the history of the veteran’s symptoms; • Obtain a copy of the veteran’s claims file; 2007 NVLSP

3. Steps to Take Before Seeking a Medical Opinion Prepare Cover Letter for Medical Expert — Letter Must: • explain the medical issue to resolve, • note that a copy of the claims file is enclosed, • summarize relevant facts and tab them in the C-file, • ask medical expert to state that he/she reviewed C-file in their response, • stress that the standard of proof is the benefit of the doubt (as likely as not) • ask detailed questions that usually can be answered with a yes or no, • invite medical expert to call you if any questions, and • (if relevant) notify the medical expert where to send their bill 2007 NVLSP

4. Advocacy Tip • Make it easy for the medical expert to agree with the veteran’s contentions. • Provide expert with continuity of symptomatology (usually w/ lay statements) • Show expert medical texts and other statements from experts that support linkage between the veteran’s current condition and service 2007 NVLSP

5. Sample Letter to Medical Expert • All letters should contain: • OPENING PARAGRAPH--introduces veteran, gives info on veteran’s condition, indicates why doctor should provide a favorable medical opinion; summarize standard of proof that is favorable to veteran. • SUMMARY OF FACTS & LAW-- Give details of service; specify injuries/problems in service; symptoms in service and post-service, treatment, other medical opinions, and other relevant info • QUESTION FOR EXPERT—be as precise as possible • CLOSING PARAGRAPH--thank expert, ask expert to indicate review of claims file, provide contact info 2007 NVLSP

6. Sample Letter to Medical Expert • Mr. Jones served July 1969 to January 1972 • Wounded in action in 1971 • Several times treated for painful feet. Bilateral foot complaints variously diagnosed as: bilateral trench feet, bilateral pes cavus, bilateral pes planus. • Separation examination showed no musculoskeletal defects. • Vet claims while in combat hurt his back several times, causing significant pain. Did not seek treatment. • After discharge, veteran had almost continuous pain in lower back, still did not seek treatment. Lay statements from family say he is a stoic. • In 1989, diagnosed with spinal stenosis. MRI provided impression of severe spinal stenosis. • In April 1989, Dr. Black indicated that vet had back problems for years; in 8/88 developed significant pain. Veteran advised to consider surgery, but did not have surgery. 2007 NVLSP

7. Sample Letter to Medical Expert • SUMMARIZE RELEVANT LAWS • Explain “benefit of the doubt” • “Therefore, I will phrase my questions to you so that you can respond to ‘Is it as likely as not.’” • Explain combat veteran advantage • “In Mr. Jones’s case, his statements about what happened to him during service all are connected to incidents that occurred when he was engaged in combat with the enemy. Therefore, for the purposes of your medical opinion, please accept his statements as proven facts.” • Explain that preexisting injury presumed to have been aggravated by service in cases where there is an increase in disability during service, unless specific finding that increase due to natural progress of disease. 2007 NVLSP

8. Sample Letter to Medical Expert • QUESTIONS: • Is it as likely as not that current severe spinal stenosis is linked to trauma suffered in service? • Assuming a preexisting back condition on entry (entry exam noted limited lumbar motion & tenderness), is it as likely as not that trauma to back in service, which resulted in increased back symptoms, aggravated preexisting back condition, and that back condition that was aggravated in service is linked to the current back condition? • SMRs show treatment for pain in feet, attributed in service to pes cavus, pes planus, and trench foot. Is it as likely as not that bilateral foot pain is connected to the current back condition? • Or, is it as likely as not that pain caused by SC trenchfoot caused or aggravated back condition? 2007 NVLSP

9. Sample Letter to Medical Expert • Thank doctor for assistance. • Make clear doctor should indicate in letter that he/she reviewed the entire claims file. • Provide contact information in case doctor has questions. 2007 NVLSP

10. Sample Letter 2 to Medical Expert • Begins by introducing the veteran, giving brief background of case, and why opinion necessary. • Opening includes paragraph that research shows that those with mental illnesses more likely to smoke. • Letter introduces the doctor to “benefit of the doubt” and low standard of proof. • Make clear what Dr.’s opinion should contain: • statement that doctor reviewed entire c-file • Reasons or bases for the doctor’s conclusions 2007 NVLSP

11. Sample Letter 2 to Medical Expert • The letter also contains a “Cautionary Note.” • “Please focus only on the psychiatric condition for which the veteran was service-connected at the time of his death and for the 47 years prior to his death—that is, anxiety disorder with depression and conversion symptoms. You said in one of your letters that he may have been misdiagnosed in the 1950s, and that his real service-connected condition might more properly be characterized as PTSD. To focus on a misdiagnosis that may have occurred about 50 years ago would probably do more harm than good to [the claimant’s] case at this point.” 2007 NVLSP

12. Sample Letter 2 to Medical Expert • Vet served 1940-1945. In 1950, received SC for chronic conversion reaction. • In 1977, he submitted documents showing he was having trouble working. RO denied increased rating • In 1993, vet stated he was worse and could not work. 1994 decision increased SC evaluation to 100% based on TDIU, effective 10/93 • 3/96 RO decision awarded 100% schedular evaluation • Vet died in 1996, due to chronic obstructive pulmonary disease due to or as a consequence of “tobacco and H[istory]/o[f] asbestosis.” Contributing causes were status post MI and status post 4-vessel bypass. • In 9/96, DIC application filed. 2007 NVLSP

13. Sample Letter 2 to Medical Expert • Advocate asked Dr. the following question : • Is it as likely as not, or better, more likely than not, that the veteran’s service-connected anxiety condition causedor aggravated (worsened) his smoking habit (nicotine addiction). We already know from the death certificate that COPD was determined to be the primary cause of his death, and that “tobacco” was considered a secondary cause. Please explain your answer. • Advocate instructed Dr. to make her “own medical determination.” Thanked Dr. 2007 NVLSP