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Benefit Of Doubt?
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Guest Morgan
We received my husband's decision letter and I have questions. First, it's important to know that my husband's doctor advised against having an exam as it was detrimental to his health. I discussed this with the rep on the 800# and he assured me it would not hurt his case if he declined the exam.
But all of his claims were denied because he didn't have the exam--"Because of conflicting medical information on file, an exam was ordered to provide more information. You canceled the exam, therefore not enough information is available to give a favorable decision on your claim."
He has medical evidence (two private IMOs) that fully confirms diagnosis and treatment of the conditions claimed. They say the private docs didn't provide treatment and lab results to support their opinions. In one IMO the supporting documentation was attached and referenced in the IMO, such as, "see evidence #4" then that document was clearly marked #4. The other doctor stated, "I have examined this patient and it is my opinion that..." He provided only his opinion, but I attached supporting VA medical records to my cover letter to prove meeting the rating criteria. VA and private medical records show diagnosis and current treatment. VA says this is not enough to support the doctors' opinions about his history and current conditions.
The main claim involves functional loss of use of both lower extremities, confirmed by two private doctors. But one VA doctor, wrote a statement in a recent record that my husband had "mild weakness and good tone in lower extremities." (He's the one who screwed up things the last time my husband was rushed to the hospital.) Here's the issue: this doctor has never even touched my husband's legs. If fact, my husband has never undressed at any time for any kind of exam by this doctor. He was always seated, fully clothed, in his wheelchair, and he only talked to the doctor. I was always with him.
A couple of months ago, I had contacted the supervisor of the nurses at the OPC about the inaccurate records in my husband's file, especially about diabetic exams for feet and legs. The supervisor called back to let me know they have, since my complaint, changed the way they enter data in the VA software program. Still the doctor's note is there and the VA used it to deny several claims.
On one hand, two IMOs with full rationale are not enough to make a favorable decision, but one VA doctor statement is enough to make an unfavorable decision, since he canceled the exam. They are saying the IMOs did not include any treating records, yet the VA doctor made only a two-line statement.
They insisted that if he doesn't go for the exam, they will not reconsider.
If a vet cannot withstand a C&P exam, and all but one inaccurate statement supports the claims, would this not be a case for applying benefit of doubt to the veteran's favor?
If anyone can help me understand this, I would greatly appreciate the help.
Edited by MorganLink to comment
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