Can Redacted Va Medical Record Be Used As Evidence Against Veteran

[VictorE]

In 2009 I saw my first VA medical doctor and after refusing to review my service medical evidence I had brought with me he put into my VA medical record inflammatory remarks that after 2 years I was able to get them redacted from the record. Can this record now be used as evidence against my claim? The medical record states on it now that a part of it was redacted. This changed the VA medical record but before I could get the statements redacted a C&P examiner used the record against me when denying my claim. I brought up this issue during my DRO hearing but of course it does not appear in the transcript of the DRP hearing and now my claim is waiting on the BVA to review my claim.

My question to my learned friends is can a VA redacted medical file be used as evidence against a Veteran? I read somewhere that a VA ruling was handed down that since the contents of the Medical record had been redacted that it no longer is valid as evidence because it changed the content of the record making it invalid.

[VictorE]

Free Spirit, thank you for all of your research and concern. I probably am howling at the moon discussing the importance of the redacted medical file. My attorney says lets first get you service connected and then go into the other issues like EED and CUE, pretty much the same thing you have said. I just get frustrated with the life I live and wish it would get resolved. I feel like I am in a standstill but its been so long now that I need to remember each day brings me closer to getting this injustice corrected.

[Philip Rogers]

Yes, it can't be used against you and it shouldn't even be there.

pr

[free_spirit_etc]

I think anything in your file can be used as evidence in your claim. I have read where people tried to get some things removed but the court said it is part of the entire history. It doesn't seem like they should be holding it against you though.

You may want to make a written statement that the C&P examiner used information that was later redacted in forming his opinion.

Edited October 19, 2013 by free_spirit_etc

[free_spirit_etc]

I just looked at some of the court decisions - and what they state is that they have to have the same unredacted records that was before the Board. But it doesn't say anything about the Board. That doesn't mean there is no rule. I just didn't see it searching the court decisions.

[VictorE]

If anyone can give me a precedent to study it will be helpful. What he said was that my disability was due to a work related injury, he gave no details of what he called an accident in 1990 even though in 1985 I went through a Physical Eval Board that determined I was injured in the line of duty and that my disability was not pre existing, my DD214 says discharged by reason of physical disability with entitlement. The statement that I fought for him to redact was that during a workmans comp suit I accepted a 1 time payment in lieu of future medical care.

The C&P examiner cited his medical record in her denial and even says that while I was diagnosed with Spondylosis, Spondylolisthesis, DDD and facet syndrome while in service that these were due to a childhood form of polyarticular arthritis and were not related to the physical trauma to my spine (LOA is in my SMR file). Yes, she ignored that I was fit upon my entry exam.

A VA citation or circuit court case would really be beneficial in helping me win this claim that I filed on a BDD claim form while still on active duty in 1985 1 month prior to my medical discharge. Have I been screwed for 28 years? YES!

[free_spirit_etc]

I don't have a case yet. But I am wondering if the C&P exam can be considered inadequate. Or if that can be an error on the part of the VA, to rely on a medical opinion that was based on information that was later redacted. Or that the RO was in error to rely on a medical opinion that ignored the presumption of soundness.

Did they deny you on the basis of the redacted information? Or did they deny you on the basis that your condition was congenital?

How did she cite his medical opinion? Can you share her opinion and share the denial letter?

Edited October 19, 2013 by free_spirit_etc