Tbi C&p Yesterday

[bufloguy]

Just had my C&P for TBI due to MVA 20 years ago. The examiner stated she read my c-file, and thanked me for putting together such a "great" claims package. She asked a few questions about the accident itself, memory, headaches, ect. Then checked my reflexes, vision, and asked about my sense of smell. On my way out the door, she stated that I was SC for TBI, and the RO willl decide my %. All totaled the exam was 7:36.

Does this sound right?

[Wings]

No problem.

Well, my opinon on the GAF would be no, the examiner would not be required to submit a GAF. The reason is the examiner was assesing(or should have been) cognative dissorder and other residuals wich is not a mental or mood dissorder. The examiner was not and did not examin the veteran for depression and anxiaty but made note of it in the exam. A GAF would be appropiate for a mental condition but is not suitable for a cognative dissorder because a person can have cognative issue and be quite happy(most of us know someone that is quite cognatively challeged that allways have a smile on their face).

What is supposed to happen by the 8045 code is if the RO has a report of mood disorder due to tbi, a C&P must be ordered and a seperate rating assigned. A GAF would be assigned at this time.

I think the veteran is working(I'm not positive). If the veteran is working, of course there will be no opinion from the examiner whether or not he's employable.

I hope that answers your questions.

Thank you Time. However, IMO, I still think the C&P Examiner might have opined on the veteran's employment/history, especially if there are current problems related to his TBI/cognative deficits. I think it would help if this report noted employment problems: subjective or objective. Something to consider for future exams. ~Wings

38 CFR 4.1 Essentials of evaluative rating.

This rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history.

[41 FR 11292, Mar. 18, 1976]

38 CFR 4.10 Functional impairment.

The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Whether the upper or lower extremities, the back or abdominal wall, the eyes or ears, or the cardiovascular, digestive, or other system, or psyche are affected, evaluations are based upon lack of usefulness, of these parts or systems, especially in self-support. This imposes upon the medical examiner the responsibility of furnishing, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of disability upon the person's ordinary activity. In this connection, it will be remembered that a person may be too disabled to engage in employment although he or she is up and about and fairly comfortable at home or upon limited activity. [41 FR 11292, Mar. 18, 1976]

38 CFR 4.2 Interpretation of examination reports.

Different examiners, at different times, will not describe the same disability in the same language. Features of the disability which must have persisted unchanged may be overlooked or a change for the better or worse may not be accurately appreciated or described. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. Each disability must be considered from the point of view of the veteran working or seeking work. If a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. [41 FR 11292, Mar. 18, 1976]

Edited October 7, 2009 by Wings

[timetowinarace]

Wings, I understand your point and don't disagree. However, I would have to read through the 8045 rating facets as each facet has it's own criteria, some of wich may include employment issues. This C&P seems to have been done directly the way tbi C&P's are supposed to, or 'by the book' with the exception of defering an opinion on the memory ect issues to the objective testing.

In my opinion, the examiner should have studied the test results and gave an opinion herself. I think this will turn out to be the bigger issue.

[Wings]

Wings, I understand your point and don't disagree. However, I would have to read through the 8045 rating facets as each facet has it's own criteria, some of wich may include employment issues. This C&P seems to have been done directly the way tbi C&P's are supposed to, or 'by the book' with the exception of defering an opinion on the memory ect issues to the objective testing.

In my opinion, the examiner should have studied the test results and gave an opinion herself. I think this will turn out to be the bigger issue.

I agree with you, and I would need to re-read the 8045 rating facets as well.

Bufloguy, stated his examination lasted a total of 7 minutes ... Therefore, I am not confident she could process this exam completely in that short amount of time. It appears she deferred to the neuropsyche testing, and ultimately those test results will or should carry as much weight as her examination.

She did a "mini" mental status exam, and noted normal psychiatric presentation, but she also noted "symptoms of PTSD and depression". I think her mini mental status exam she should have assigned a GAF score --hopefully these issues will be resolved with the C&P for PTSD/Depression.

I am not experienced with TBI issues, so I defer to ya'll.

Just adding my 2 cents, for all that's worth :-) ~Wings, over and out!

[bufloguy]

Got the Brown Envelope Today . . . TBI 70%, PTSD deneid. Guess that the examiner only needed 7 mins for the exam.

[timetowinarace]

Glad to hear it worked out.

Are you going to pursue the PTSD?

[Wings]

Got the Brown Envelope Today . . . TBI 70%, PTSD deneid. Guess that the examiner only needed 7 mins for the exam.

APPEAL!!!

C&P Examination Inadequate for Rating Purposes !!!