tdiu Unsigned Medical Report

[Charleese]

Hi all,

As you know my husband's friend was denied TDIU, cervical myelopathy and low back condition which was secondary to his right knee injury. I posted here several days ago under TDIU Denied if you care to get a background of TDIU. However, in VA's decision they used a Doctor's Progressive Notes which was never signed by a doctor nor states doctor's name on note to deny him service condition on a secondary basis. The note states in part: ".......These records document your reports as to the circumstances of your fall, to include stepping from your car and missing a step and falling, falling while making a delivery on the job, and falling after getting out of your ar, however, there is no indication that you reported that your fall was related to your service connected right lower extremity disability." It goes on to further state: The evidence does not show that residuals of cervical myclopathy, Brown-Sequard Syndrome, with quadriparesis, status post anterior discectomy, fusion, and plating at C3-C4 is related to the service-connected condition of residuals of fracture right tibial tubercle with osteoarthritic changes and chronic chondromalacia of the knee. Therefore, service connection, on a secondary basis is not established. Furthermore, as there is no evidence of this diability during military service, service connection, on a direct basis, is also denied.

As you know he has a signed Hospital Consultation Request signed by Hospital Nureo Surgeon stating that he fell because of his right knee service connected injury,which VA conviently failed to use. Consultation Request was done on o8/5/08 and Progress Note was done 8/15/08. Vet denies emphatically telling anyone "that he missed a step and fell."

My question is do anyone know whether VA can use an unsigned Medical Report without doctor' name on it as evidence to deny a claim. If there is a regulation on this please post.

Thanks in advance for your replies.

[Charleese]

This is not a VA Medical Record, this is a Hospital Medical Record that is unsigned that VA use to deny vet with. VA cannot manufacture virtual signatures because vet has copy of this document as well.

I still don't understand the decision in this unsigned report case. Can someone please explain it to me. Are they saying that the VA can use an unsigned medical report to deny a vet's claim. Does this decvision apply to my husband's friend claim. Thanks!

[Berta]

"My question is do anyone know whether VA can use an unsigned Medical Report without doctor' name on it as evidence to deny a claim. If there is a regulation on this please post."

Charleese -can the discussion under the Legal Beagle post today help you here?

These statements by VA have to be strongly rebutted.

"As you know he has a signed Hospital Consultation Request signed by Hospital Nureo Surgeon stating that he fell because of his right knee service connected injury,which VA conviently failed to use."

Did they list this as evidence and then fail to use this in the narrative-or simply ignore it even in the evidence list- --if so_ I suggest he file a Request for Reconsideration as they failed to properly consider all of his evidence.

The reconsideration request however does not stop the clock on any other appealate deadlines they gave him.

Did the Neuro Surgeon just describe what your husband said or can this doc be asked to provide a medical rationale for what is in the report?

Does your husband have evidence from his employer (I assume that he is unemployed due to this now)

that any fall he had affected his job?

"Vet's Primary Doctor wrote one and rater is saying that providers statements/nexus was purely speculative because they were not at the scene of accident, nor involved in the medical care rendered subsequent to this event. This is not true and his Primary Doctor intends to issue another IMO as well as refute this for him."

This will help him.

Was there documented medical care right after the accident and does VA have that info?

This can certainly be refutted and it sort of ticks me off as to what the rater said-

"Vet's Primary Doctor wrote one and rater is saying that providers statements/nexus was purely speculative because they were not at the scene of accident, nor involved in the medical care rendered subsequent to this event."

it is like saying a vet with a combat disabilty such as a gunshot wound, a PH and proof of combat service has Provider's statements that are purely speculative because the provider was not in the exact same battle with the vet.

Hokey- and I guess "speculative" is becoming the VA's new signature wording in order to deny claims.

A C & P PA said Speculative regarding my AO claim-(in the face of overwhelming evidence) and the BVA completely disregarded his opinion.

[Charleese]

Berta, thanks a lot for this reply,

The Legal Begal post helps a lot. This document not only was unsigned but it doesn't list a doctor's name on it at all, so you don't know who wrote this Note.

No they did not list plus ignored the Consultation Request as evidence in the decision, so he can use that, along with his doctor's new IMO and rebuttal.

The nureo surgeon in his report states: "since last week right leg which gives out on occasions causing multiple falls. Approx 1-2 weeks ago was in car when (____________ cannot understand words that he wrote) got out of car and both legs given out. Then he goes on to use these medical terms escribing C2-C3 as through C6-C7.

The nureo surgeon who performed his operation wrote a statement saying: Mr. is under my neurosurgical care status post cervical surgery for cervical myelopathy, cervical myelomalacia, cervical disc herniation resulting from a work related injury. It is my neurosurgical opinion that he is totally and permanently disabled from his job working for a courier service." His primary doctor wrote: "After a complete review of his medical records, it is my medical opinon that Mr. X fell because of the pain, stiftness and instability of his right knee related to the injury suffered at the time of service in the Air Force. Furthermore, it is my opinion that Mr. X is permanently disabled and unemployable after the cervical spinal surgery and several other commorbidities. Before that he wrote: "Working as a courier on July 30, 2008 he got out of the car and lost his balanve as his right knee got very still. He fell awkwardly and developed left upper extremity and left lower extremity paresis. He required neurosurgical surger on his cervical spine because of a large disc herniation."

Yes VA has well documented medical care before and after surgery.

Any help you can give me to give this vet is greatly appreciated.