ptsd Newbie - Just Had 1st C&p Only Basic Phy?

[dtclou]

Hi everyone, first I want to thank you all for your valuable information & time you put into helping all that come here.

I have been helping my husband file for disability compensation. He has been going to the VA hospital since 99' getting tests done, but no one (except me) told him he should file for comp. After years of getting worse he decided to file in March 03, but didn't follow thru. Then decided again in March 05'.

He is a Gulf War Vet. & has numerous problems in addition to Gulf War Illness conditions (gastric cramps,horrible memory, random highblood pressure,diarreah, insomnia,depression, skin growths some removed at VA, lypoma removed at VA, rectal bleeding, fatigue, his hands have started shaking receintly, muscle cramps..) His eyes are extreamly sinsitive to light & have brown spots in the whites.

He also was diagnosed in April 01' with PTSD at the VA (still no one told him to file) He has horrible night sweats, extreamly moody, impulse control, anti social-very reclussive & depressed.

He also had a back injury in service. He fell off a helicoptor rope onto a ships deck doing a fast roping excersise & had to have his L4-L5 fused.

Additionally he ate some fruit with toxic pesticide on it in Isreal. He was found in the field & taken back to an aircraft carrier & had to have part of his colon removed. He only knows what his team told him 2 weeks later when he woke up.

He went to a C&P exam on Friday. All they gave him was a basic physical. I was not allowed to go in the room with him - even though he asked several times - he cannot remember things very well. He came out very upset & worried. He said the examiner couldn't find any records of his back injury or the fruit incident nor any operations. He is very worried they will think he is making things up.

At the C&P the examiner wouldn't address any thing but basic physical stuff. She did no rang of motion tests for his back. No memory test, no mental exam. She said they would need to line up tests for some of his symptoms (stomach/colon), he said they had already done them years ago. She looked back & found them & said - oh, yes they did - good, nothing is wrong with you.

So my questions for now are -

1.Do we need to request more C&P's for the other issues - or wait to see if they already have info from VA & didn't think other tests were necessary?

2.What about all the missing service medical records? I ordered copies off the link for smr, but haven't gotten them yet.

3.Is it normal to get just a basic physical C&P ?

He also fell off a roof in Jan 05' & receintly had surgery (civilian Dr-VA said nothing wrong) to fuse his ankle together. He hasn't worked since then. He had a construction partnership with his brother before, but they had decided to end that before the ankle injury due to PTSD issues with my husband - he just couldn't work with him anymore.

I have no idea what his rating will be, but what about IU?

Does he have to fill out a special form to apply or is that something they automatically check for or send us a form if he may qualify? If he needs to fill out a form - should he go ahead & do it now before an initial rating or wait to see what they rate him at?

Thanks for any help.

[Guest Berta]

I hope he has put all of these conditions into his claim-

If I were you I would have the vet send a letter to the VAMC whch treats him- to get a copy of all of his VA medical records-

the PTSD diagnosis must have been followed up with treatment and medication records-since 2001-(as well as the other issues)

How long has it been since you requested the SMRs?

It usually take- 4-6 weeks-sometimes longer-

[Jay Johnson]

Few things:

1) find out who treated him for the fruit incident and contact them for first hand accounts of the story and try to track down those records...my guess would be that the people treating him would easily recall such an odd story and accounts from the people that treated him are as good as medical records.

2) Get him to a civilian doctor ASAP and have that doctor give a thorough evaluation of ALL of the disorders you are applying for. The VA docs are trained to only give as much info as they absolutely have to based on the medical evidence...don't expect a VA doc to assume anything. A civilian doctor may be more willing to investigate the symptoms on his behalf.

3) You will need to formerly request TDIU...the VA can grant it without a request, but it would be more likely that they wouldn't. I don't have the exact form number on hand, but the people ehre at hadit know it by heart:-)

Basically, expect to do their work for them...they will not rate in your favor based on insufficient evidence (quite the opposite in fact). Make copies of every medical piece of evidence you can find and every account from every person you can contact and present a well rounded full-proof case that they cannot deny. Even highlite the parts of the evidence that favor him most, as the raters are notorius for skimming evidence. In other words, present his case to them as if they were 6 yr olds with attention deficit disorder:-)

[wallyg]

I agree with what Berta and Jay said, but the first thing that I would do, is file a Release of Information form (VA Form 10-5345) at the VA Medical Center (VAMC) where the examination was performed.

Specify that you request a copy of the C&P examination, and all supplemental evidence for your personal records. Since VA has now established a system where they will not release a copy of the C&P at the VAMC, expect a wait until the VA Regional Office (VARO) gets around to sending it.

You MAY be lucky, and your local VARO may not have started to implement the revised regulation yet, in which case, you can get it direct from the VAMC.

This will give you the examiners name, (not necessarily an MD).

Read the report, and compare it with the Service Medical Records (SMRs) when you get them, and/or review it with your husband. Go here:

http://www.vba.va.gov/bln/21/Benefits/exams/index.htm

and review all the worksheets that should be used to cover your husband's Service Connected (SC) problems. Use the relevant ones to compare to what the C&P report states. Where you have significant disagreement based upon the worksheet data, or personal opinion, document it.

You can file a formal Letter of Complaint to the VAMC Patient Rep/Director/Manager about the problems that you perceive, before you receive a copy of the report, if you wish. Then do the the review, and follow it up with detailed comments.

I think it is advantageous when filing a complaint, to print out the relevant C&P worksheets, highlight all the problem areas; I use two colors, one for omissions and another for inadequate/incomplete.

Edited November 21, 2005 by wallyg

[Pete53]

First of all thank you for helping your Veteran. If you can document the problems he should not have to much of a problem being service connected. Berta and Jay gave you some good suggestions. I recommend that you explore the Hadit Home Page for information.

Its fairly obvious that your husband did not get a proper C&P but you should request a copy of it from the Hospital it was given at.

If your husband is unable to work you should also apply for Social Security immediately as they have a time limit for claims.

Good Luck

[dtclou]

Thank you Berta, Jay, Wallyg & Pete,

My husband did call our VARO today & check to see if he needed more C&P's - they said no - they had all the info they needed & should hear something in a couple of weeks. I am not sure what to think.......

They did require a stressor letter - which took him quite a long while to write, but he did get that in a couple months ago - The VAMC did put him on med several times, but he didn't stay on it. We are 2 hr away from the VAMC. He has gone in a couple times every year since 99' so they do have records/documentation of him having problems for a long while.

I guess the C&P was to make sc? I'm really not sure what to think now-it was so basic & didn't address any of his main illnesses/disabilities?

On finding the ones that treated him for the fruit incident - it was overseas in Isreal & he was then taken to an aircraft carrier. This was back in 91 - he gave that info to the VARO - (they did send us a request for more info to help them locate records on this & his back) - but the VA hospital said they didn't have them. I know there has to be records somewhere. Maybe once we get a copy of his smr I can look thru & find it or atleast find a lead on a contact?

I ordered his msr off the internet. He signed the form & I mailed it about 4 weeks ago. I got an email about 2 weeks ago that said his records were not there, they were at a different location. I am assuming they forward the request? The email said not to reply it was automated. Is this normal?

I saw posts saying it is a good idea to get a copy of his c-file from VARO. Would they provide us with the C&P & VA records or should we request them from both places?

Also, should I go ahead & request these now before the initial decesion or wait for the 1st rating/decession to come in before getting these?

I found the form for IU - thanks for letting me know, I will have him fill it out. Should we send it now, before the 1st rating decession or wait & send it if we need to file a nod? (I know I am being optimistic with the "if" - but who knows...)

I just made him an appointment for a full physical with a civillian Dr & will take a list off all his conditions.

Thanks again for all your help.

dtclou

[Guest Berta]

It sounds like the VA is focusing on the PTSD part of the claim-

I would get a copy of his med records-and the C & P results- although it could hold up the claim a little- but in my opinion- it is better to wait a little longer for a decision- if you know what they are basing it on.

I remembered yesterday- that when I sent for my husband's SMRs- I only got his Navy records, because the others -USMC records -were at the VARO in his claims file-seems they sent a letter indicating this-

(or maybe in his SSA file)

question all- has anyone here ever asked the VA itself for a copy of their SMRs?

At some point they become part of the c file-