Why Did VA Request An Independent Medical Exam When We've Already Had One?

[proudmarinevetwifey 0]

My husband( a Marine combat vet - infantry) received a call today that the VA is scheduling him an Independent Medical Exam. He is currently rated at 40% (Dec 2013) for back, knees, hip - service connected. When he only won 40% we appealed the decision and hired a lawyer. The lawyer immediately sent us to a specialist for my husband's specific disabilities which also cost us a small fortune, for an Independent medical exam. We found out after a battery of tests that my husband's condition was much worse than the VA's lousy exam expressed(big surprise there huh?). Our lawyer wrote up his case including this well documented evidence from our Independent Medical exam and documentation showing my husband's in service medical reports. First we had a de novo review with the help of our congressman where they didn't even read any of the paperwork because they didn't even put the right hip or knee on the report and basically said your exam doesn't mean squat and ours which didn't even include a specialist or the correct testing means more. So we are now waiting for a DRO review since November 2015.

Questions: 1. Why do they want one of their hired "independent" companies to do yet another exam on my husband? It is to try and weasel out of giving him the disability he deserves?

                   2. Now I am so worried by the VA's actions that I'm concerned they will try and take his 40% away from him as well and this appointment for the Independent medical exam will do that. Is that a possibility?

                   3. Does the fact they are setting up an appointment for this Independent Medical exam mean we are getting close to his DRO hearing?

The VA worries me to no end. I would appreciate any info or experience y'all have.

[Berta 3,196]

." We found out after a battery of tests that my husband's condition was much worse than the VA's lousy exam expressed(big surprise there huh?)"

Has all of his care been through the VA? If so, has the lawyer questioned that care,since a battery of tests revealed his condition was worse than he thought ?

." Our lawyer wrote up his case including this well documented evidence from our Independent Medical exam and documentation showing my husband's in service medical reports.  "

Sine the 40% was already granted, I dont see why the SMRs were even an issue.

He had a de novo review yet you are getting another DRO review?

It is possible. I got 2 DRO reviews once...same DRO however and she could not read my IMO either time.

Questions:" 1. Why do they want one of their hired "independent" companies to do yet another exam on my husband? It is to try and weasel out of giving him the disability he deserves?"

If they definitely had that IMO ,it is possible they realized they screwed up and need to give him  a better C & P exam

(they try to weasel out of all Comp claims if they think they can get away with it)

Can you scan and attach their Reasons and Bases and Evidence list of the VA's last correspondence on this?

I assume they denied a higher rating.(Cover C file etc prior to scanning it)

Do you have a copy of the C & P exam that they used for the denial?

If so have you googled the doctor who did it to see if they are a real doctor, or a nurse or a PA? And what their qualifications are regarding this specific type of disability?

Did the IMO/IME  follow the IMO criteria here at hadit?

Can you scan and attach that opinion here too?

I sure wonder what kind of bull crap they came up with to go against the specialist's opinion.

Cripes they tried to go against a top cardio opinion I had last year...the opinion came from VA Central's chief cardiologist. I think their posthumous C & P crapola( the veteran ,my husband,was dead for 20 years but this cardio opinion had been established into the record in 1997 and the doc is still at VACO specializing in exactly what this claim was for.) was written by the guy who fills their paper cup dispenser at their water cooler at Buffalo VARO.

It was that absurd.

And how did they handle Relative Equipoise?   We need to see the actual words of the VA.

 

 

[Vync 1,427]

55 minutes ago, proudmarinevetwifey said:

My husband( a Marine combat vet - infantry) received a call today that the VA is scheduling him an Independent Medical Exam. He is currently rated at 40% (Dec 2013) for back, knees, hip - service connected. When he only won 40% we appealed the decision and hired a lawyer. The lawyer immediately sent us to a specialist for my husband's specific disabilities which also cost us a small fortune, for an Independent medical exam. We found out after a battery of tests that my husband's condition was much worse than the VA's lousy exam expressed(big surprise there huh?). Our lawyer wrote up his case including this well documented evidence from our Independent Medical exam and documentation showing my husband's in service medical reports. First we had a de novo review with the help of our congressman where they didn't even read any of the paperwork because they didn't even put the right hip or knee on the report and basically said your exam doesn't mean squat and ours which didn't even include a specialist or the correct testing means more. So we are now waiting for a DRO review since November 2015.

Questions: 1. Why do they want one of their hired "independent" companies to do yet another exam on my husband? It is to try and weasel out of giving him the disability he deserves?

                   2. Now I am so worried by the VA's actions that I'm concerned they will try and take his 40% away from him as well and this appointment for the Independent medical exam will do that. Is that a possibility?

                   3. Does the fact they are setting up an appointment for this Independent Medical exam mean we are getting close to his DRO hearing?

The VA worries me to no end. I would appreciate any info or experience y'all have.

Welcome to Hadit!

I'll try to help you out.
 

The VA may have contracted his C&P exam to QTC. They are "independent" of the VA, but only because they are contractors.

It is not uncommon for the VA to request additional C&P exams:
- If a condition is temporary (i.e. after surgery) or expected to improve
- If a notice of disagreement/appeal was filed and the last C&P exam is rather old, etc.. need a current evaluation
- A request for an increased rating was filed

You indicated paying a small fortune to a non-VA doctor for a medical opinion. Usually these are needed when trying to obtain service connection (SC). The three items below are required for SC status:
1. Event/injury in service
2. Current diagnosis
3. Doctor opining #1 caused #2

Once SC has been established, then the disabilities are rated. Each disability rating is determined independently (back, knees, hip, etc...) and represented as individual percentages.

You can learn about the rating criteria for any given disability by looking up the schedule of ratings tables in this link:
http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=38:1.0.1.1.5

 

If you have not already, I recommend you familiarize yourself with the tables for each of your husband's disabilities. Check the criteria for his current percentage and then check his medical records. It is not unusual for a veteran to qualify for a higher percentage and not realize it. You can go back 12 calendar months and submit evidence for an increased rating. There should be no need to pay an outside doctor a small fortune because SC status is already granted.

In addition, consider secondary ratings. It's the old "thigh bone is connected to the hip bone" deal. For example, if his back disability causes another disability, like sciatica, he can file a claim for secondary SC. Or if his chronic back pain causes him depression, that's another one. A medical opinion connecting the two will be needed, but it if it cut and dry you might let the VA try to do the connecting for you. One thing people forget is medication used to treat a SC disability can count too. If the NSAIDs (ibuprofen) he took daily for back pain for years caused acid reflux/erosions, that can be claimed too. If his left knee is so bad that his gait changed and now his right knees is bad, that can be claimed too.

Once the individual percentages are determined, the "combined rating" is calculated. This uses funky math as indicated in the link below. His 40% rating is his "combined rating". 10% for a knee + 10% for a hip does not equal 20% combined. It equals 19%, but is rounded to the nearest 10%. A 40% combined rating could be a single 40% or an odd combo like 20%/10%/10%/10%. As the combined rating gets closer to 100%, it becomes more difficult to jump to the next 10% tier. You can get additional SC for 10% ratings, but it might not push the rating to 95%, which would round up to 100%.
http://www.benefits.va.gov/compensation/rates-index.asp#combinedRatingsTable1

Individual disability ratings can actually be reduced for situations like:
- Meeting the criteria for a lower disability rating percentage
- Disability considered temporary (i.e. period after surgery) or expected to improve (i.e. due to treatment)
- Veteran has been found to show sustained improvement over time

If a veteran is found to have fraudulently obtained their disability, it can be cancelled outright.

If a veteran goes to jail, disability payments will not be paid until they get out.

If the VA wanted to reduce a rating, they would first have to have proof that he no longer meets the criteria for the current percentage level of a specific disability. They will need to send him a letter in the mail stating they are proposing a reduction and explain why. Make sure your address is correct so you do not miss out on any letters. You are given a certain amount of time to submit evidence proving otherwise before they reduce the rating.

There are rating protection rules too, if he maintains a current % for X number of years:
5 years: VA must prove sustained improvement to reduce; otherwise the disability is considered stable
10 years: The VA cannot sever service connection
20 years: The VA cannot reduce the percentage
After the veteran turns 55, they are less likely to reduce too.

You might be getting closer to the DRO meeting, but honestly most DRO appointments can take months or even years. If there is a hardship (going to lose your home, terminal illness, etc...), the VA can speed these things up. DRO's are a mixed bag. Some people, like me, have had good experiences while others have not.

 

I hope this helps

[pwrslm 354]

The one thing you dont want to do is miss the C&P exam.  If it happens, get on the phone and get it reschedules ASAP.  Do not give them a chance to say you were a no show.

Edited June 23, 2016 by pwrslm

[Hamslice 337]

What he said ^^^^^^^^^^^^^^^^^^^^^^^^^^^^

Hamslice

 

 

[Andyman73 882]

No where as easy as it sounds. Such a drag, too, the VA will try to outwait and outlast you.