Initial Claim Denial - Help

[KMoeller68]

Hello,

I am an Honorably Discharged Female USAF Gulf Era Veteran. While in the Service I was operated on, and diagnosed, with a medical condition called Endometriosis. In conversations with the doctor, I was told I had Stage 4 Endometriosis and given several options on how to control symptoms, etc. This was in August of 1992 while stationed at Malmstrom AFB, MT. In December of that same year, I had several things go wrong and was back and forth to the OBGYN at the clinic. After about a month of exams, tests and medications, I got a call from my First Sgt. While in his office, he explained to me that the only way to treat my condition was through something called "Uterine Cauterization". I asked if that would relieve my symptoms, but allow me in the future, to have children...and he responded "No, I wouldn't be able to have children if I had the procedure." So, I declined. I was confused as to why my First Sgt. was the one to have this discussion with me, so I went back to the Doctor that did the surgery and he explained that he was able to get all the lesions from the endo during surgery, but that I also had 'internal endo' which was located inside the uterus, and without the cauterization process, he could only give me meds to help with the pain and symptoms...so we went with that.

At the end of visit, he asked me if I wanted children in the future, was that why I declined the cauterization procedure, and I said yes. He wrote out prescriptions for me and I got them filled.

A few months later, I find out I'm pregnant (May 1993). I go back to the Doctor and he explained that one of the medications he provided me was called "Provera"....which is a drug prescribed for women with Endometriosis, but it also is used in conjunction with fertility! My doctor did not tell me anything about this medication other than it would help with the (sorry if it's too much info!) bleeding issues I was having. My Commander was not happy I was pregnant and bascially pushed me to get out of the AF and I seperated 15 Aug 1993.

I didn't have any of the Seperation appointments that are normally set up...I didn't have a medical exam, or anything. I was just sent to admin to help fill out my DD214 Form, and that was that. I didn't know to ask for my medical records, or anything.

Fast forward to April of 2010...I find out that I should have been told to report to the VA to start a claim as soon as I got home as a civilian. I missed out on my GI Bill for the same reasons...I had no clue that the medical condition I was diagnosed while in the military for entitled me to compensation. So, I fill out the claim a year ago April.

In that claim, I also ask for Adenomyosis as a secondary diagnosis to the Endometriosis. I was diagnosed with Adenomyosis in 2003...it is what is considered "Internal Endometriosis", which was why I was offered the Cauterization procedure for while in the military. Due to the Adenomyosis, I had to be put on a medication called Depot Lupron for an extended period of time to get my symptoms under control...this caused Osteopenia in my left foot and ankle....which in 2005, I injured so much so, I required donor tendon and grafting....which my body rejected due to contaminated subcutaneous sutures...causing me to go septic...I was inpatient for 6 days, almost lost my life and almost my foot. I was able to keep both by the grace of God, but my foot is so bad now, that I have included this as part of my claim. Had it not been for the Adenomyosis, the Lupron would not have been needed, and I would not have had the Osteopenia, which is why I hurt my foot...

I've been denied all three as of June 22, 2011. I am told there is nothing in my military records indicating Endometriosis...only 'bleeding issues'.

How can that be? How can I come up with these conversations, surgeries, diagnoses and prescribed medications unless I actually HAD THEM????

I also recevied a letter from the DAV offering assistance...which I will call on Monday. However, I want to point out that I spoke to two different VA people (one from 800 #, Louis a Case Manager) and the Doctor that I had to see for the C&P Exam....they BOTH confirmed that the Endometriosis was service connected in conversations. I also brought copies of my medical records (not my SMR, but all civillian records) when I filled out my claim and to my C&P Exam...and neither time did they want anything to do with them...they kept telling me they had received all medical records required in order to make a decision....but in the decision, it states they were missing several of the items I HAVE COPIES OF and tried to provide them. Ugh!!!!!

HELP!!! What do I do????

[USNDW]

I would recommend first thing you do Monday morning before calling the DAV, call the Hospital where you had surgery and the pharmacy where you got your meds filled and ask for a copy of the records. Without those you are going to be in a real tough spot.

[Chuck75]

Without getting into the details - -

The VA has a thing about denials. Seems that is the preferred way to get a claim "off their back".

The military has a record of doing things to reduce or eliminate possible medically related costs.

The best option for you that I can see is to file an NOD (notice of disagreement) with the VA, and consult with a lawyer specializing in VA and military compensation law.

You may need to hire a lawyer to delve into what might be possible with the military, since the discharge process seems to have been less than it should have been.

Make sure that you have and keep the necessary medical and other records in your possession. The VA can be quite loss prone when it is to their advantage to do so.

There are actually laws against such things, but the problem is proving deliberate intent rather than accidental loss.

Don't wait too long, time is against you.

Edited June 26, 2011 by Chuck75

[sawgunner]

I had to go through my congresscritter to get my records.

Actually.... In one case I called up the medical records office on post and asked the lady I spoke with to give me her first and last name...

She asked... Why do you need that information??? I responded with... My congressman has asked that I document everyone that I speak with in reference to my VA claim... "He did not tell me to do that".. She gave me her name and within seconds I had the records that I had been trying to find for over 5 years. It was like magic.

Good luck to you.

Hang in there ans stick with it.

It sounds to me like you have a very strog case.

[broncovet]

K

You have been given mostly good advice. You need to file a Notice of Disagreement with the RO that did your decision within one year of the decision. If you have not already done so, then you should focus on the NOD as it is your next step.

Since you were clearly missing records, you may have a good result with electing a "DRO Review". A senior rating specialist will review your file and issue a new decision. If this decision is also denied, then your next step would also be to file a NOD on that decision and this time, you would elect for a Board of Veterans Appeals.

While some people with their NOD simply state:

Notice of Disagreement Jane P. Veteran 123-45-3500

I disagree with the decision dated May 16, 2011 and elect a DRO Review on the following issues:

1. Denial of Endometriosis

2. Denial of secondary conditions.

3. I also disagree with any possible "deemed denials" that were not adjuticated.

Signed,

Jane P. Veteran June 26, 2011.

While the above "short form" NOD has what you need, I like to submit more evidence right on the NOD to make my case, for example, as above:

......

1. Denial of Endometriosis. On 6-3-1993 Dr. P. Smith, at the Ft. Lewis VAMC diagnosed Endo, and recommend a procedure that would render me sterile. I declined the procedure and took his prescribed meds instead. I have enclosed my "ebenefits" pharma records, which shows I was prescribed these meds...as well as a copy of his medical exam. ETC, ETC.

2. The Secondary condition of ....was diagnosed on ....by Dr. Ima Quack at the VAMC center, where I nearly lost my foot and my life.....on ....date.. etc. etc..

The only point to which I disagree with the advice given is that it may be a bit premature for you to get a lawyer. Dont get me wrong...if you can afford it, go for it. However, many times this early in the appeal process you can do many of these things yourself. At the DRO and BVA level of appeals, most Vets do not get lawyers. While I strongly feel that you are entitled to attorney representation if you so elect, it would seem a bit premature at this time. However, I dont know you...I dont know your finances, your responsibilities, your medical history, etc, and you, if you think it is in your best interest, by all means hire a lawyer. I am simply suggesting most Vets dont hire an attorney until at least the BVA or CAVC level of appealate review.

[Berta]

If you have copies of the actual SMRs that indicate exactly what your condition was and the inservice treatment records, the DAV might support a request for reconsideration of the denial as it was not based on all evidence of record in your SMRs.

This will not stop the NOD clock (one year after the decision) however so best to mark your calendar if the DAV supports this type of request but then-if VA does not act on it- the NOD can be filed prior to that year NOD deadline.

You can obtain a lawyer when the NOD is filed.

There has been discussion here recently on "newly discovered service records".

That regulation too might help your claim.

"..they kept telling me they had received all medical records required in order to make a decision....but in the decision, it states they were missing several of the items I HAVE COPIES OF and tried to provide them"

Did they even acknowledge receipt of the copies you had?

[Philip Rogers]

K - all the advice you've received here is pretty accurate. I believe you need to get your SMC's from the National Personnel Records Ctr (NPRC), or wherever the AF keeps them. I think it's still the NPRC but I'm not sure. Don't count on the VA getting those records, for you. You should also get a complete copy of you VA claims file (c-file), so you know what evidence they had when they made their decision.

Personally, I don't recommend using a VSO, as most I've seen are quite lazy and draw their approx $35k annually by doing mostly nothing. Most give misinformation that they are taught by the VA. There is excellent help here and you can come back often and ask what's needed.

You do have a yr to NOD and you must be sure not to miss that deadline.

pr

Edited June 26, 2011 by Philip Rogers