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UN-Diagnosed TBI while on Active Duty


FC1
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In 1990 I was in a high speed MVA which resulted in me being conscious for approx 2 hours and the vehicle had to be cut from around me to extract me from underneath a semi trailer which jack-knifed in front of me on an icy bridge.  I was taken to a civilian trauma center and the doctors and nurse asked if I remember what happened, what day it was, where I am which I had no idea.  The nurse told me her name and came back a few minutes later and asked if I remembered her name which I didn't.  It took several times over several hours of her telling me her name before I remembered it....

Fast forward to 2019 I file for the following disabilities:

PTSD:

I filed a claim for PTSD and TBI from the car accident in 2019.  The PTSD C&P VA psych said I have diagnosed panic attacks, anxiety, and depression...but not PTSD.  I didn't have painic attacks, anxiety or depression before the car accident or 20 years of military service.  I have been diagnosed with PTSD from two separate civilian doctors which I submitted the health records and civilian diagnosis results with my PTSD claim but was shot down.

Service connection for post traumatic stress disorder with panic attacks and depression.  Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. (38 CFR 3.303)
Service connection for post traumatic stress disorder with panic attacks and depression is denied since this condition neither occurred in nor was caused by service. (38 CFR 3.303, 38 CFR 3.304)
Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.
We did not find a link between your medical condition and military service.
The VA medical opinion found no link between your diagnosed medical condition and military service.
The examiner diagnosed you with unspecified anxiety disorder, however the examiner did not link your diagnosis to your motor vehicle accident during service.

Favorable Findings identified in this decision:
Medical records show a diagnosis of unspecified anxiety disorder.
A stressor is conceded based on motor vehicle accident in service.

I guess almost dying and being permanently injured an motor vehicle accident doesn't cause PTSD, anxiety, depression...just ask my wife who has to practically beg me to get in a car and drive any where.

 

I also broke my left collar bone from the seat belt restraining me.  The VA gave 20% for the broken collar bone but denies my left shoulder pain is military related even though I went to medical several times and complained of AC joint shoulder pain which is clearly stated in my medical records.  I also had my knees hyper-extended by the dashboard collapsing on my knees for about 45-60 minutes before the fire department was able to cut the roof off, pry the door open and jack up the dash board.  The VA granted me 10% for my left knee because I reported left knee pain about 1 year after the car accident.  Now my right knee has pain and will dis-locate and pop back in while walking.

VA Results:

Left Clavicle:

Evaluation of residuals, left clavicle fracture (non-dominant) currently evaluated as 0 percent disabling.  The evaluation of residuals, left clavicle fracture (non-dominant) is increased to 20 percent disabling effective September 27, 2019. (38 CFR 4.1, 38 CFR 3.400)  The effective date of this increase is September 27, 2019, which is the date we received your "intent to file" communication. When an increased evaluation is granted based on VA medical evidence showing an increase in disability after the date the claim was received, and the claim was received within one year of the “intent to file,” the effective date is the day VA received the “intent to file.” (38 CFR 3.155) (38 CFR 3.400)  We have assigned a 20 percent evaluation for your residuals, left clavicle fracture (claimed as left broken collar bone) based on: 
• Painful motion of the shoulder. (38 CFR §4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint.  Since you demonstrate painful motion of the arm at the shoulder, the minimum compensable evaluation of 20 percent is assigned) The provisions of 38 CFR §4.40 and §4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca v. Brown and Mitchell v. Shinseki, have been considered and applied under 38 CFR §4.59.  A higher evaluation of 30 percent is not warranted for limitation of motion of the arm unless the evidence shows:
• Limited motion of the arm to 25 degrees from the side. (38 CFR 4.69, 38 CFR 4.71
A noncompensable evaluation is assigned unless there is a malunion or nonunion of the clavicle or scapula. (38 CFR 4.31, 38 CFR 4.71a)

Left Should AC Joint/Rotator Cuff:

Service connection for left shoulder rotator cuff (non-dominant) as secondary to the service-connected disability of residuals, left clavicle fracture (non-dominant).  Service connection may be granted for a disease or injury which resulted from a service-
connected disability or was aggravated thereby. The evidence does not show that left shoulder rotator cuff (non-dominant) is related to the service-connected condition of residuals, left clavicle fracture (non-dominant), nor is there any evidence of this disability during military
service. (38 CFR 3.303, 38 CFR 3.306, 38 CFR 3.310)  The evidence does not show that your condition resulted from, or was aggravated by, a service-connected disability. (38 CFR 3.303, 38 CFR 3.304)
The medical examiner stated that your symptoms are subjective only. Objective exam is normal for a rotator cuff tear. There is no objective evidence of a chronic rotator cuff condition. A nexus has not been established.
Favorable Findings identified in this decision:  The claimed primary disability is service-connected.

 

The TBI C&P VA doctor reviewed my records from the civilian trauma center and said "You have a Moderate TBI."  The VA rating "specialist" said the opposite.

Traumatic Brain Injury:

Service connection for traumatic brain injury.  Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. Service connection for traumatic brain injury is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed. (38 CFR 3.303)  While your service treatment records reflect complaints, treatment, or a diagnosis similar to that claimed, the medical evidence supports the conclusion that a persistent disability was not present in service. (38 CFR 3.303)  The VA medical opinion found no persistent disability as the traumatic brain injury has resolved.  The examiner stated that there is clear documentation objectively from medical personnel that this veteran suffered a moderate TBI on December 15, 1990 at age 20 years old while active duty USN. The ER notes state a diagnosis of "closed head injury." Additionally the subjective statements by the veteran are consistent with the objective medical record and also by his statements alone establish that a TBI occurred. However, the medical records in 1995 and 1999 showed "no residual problems". Therefore, service connection for traumatic brain injury is denied since this condition has resolved.
Favorable Findings identified in this decision:
The evidence shows that a qualifying event, injury, or disease had its onset during your service.

 

My medical records show a TBI happened but the VA is judging their finding on "ANNUAL" physicals I received in 1995 and 1999....I'll let that sink in for a minute...annual physicals from 1995 and 1999...I have annual physicals every 4 to 5 years.  Not once in 22 years of military service did any medical professional ask about my unconscious episode and if I have any residuals....because TRAUMATIC BRAIN INJURY WAS NOT DEFINED BY THE VA AND DOD UNTIL MAY 2007.

How am I suppose to know the symptoms or any military medical professional is suppose to know what to look for?

To get diagnosed at a civilian facility it will cost me $1500 because of my insurance minimum has not been met this year.

I am seeing a civilian psychologist to help with PTSD, anxiety, and depression and paying for it out of pocket.  He recommenced I get a neuro-psych exam.

Does the VA do neuro-psych testing for veterans who slipped thru the cracks of the medical system?

 

The symptoms I am experiencing are like a checklist for TBI.  This list of symptoms is from the Mayo Clinic website.

Physical symptoms

  • Loss of consciousness from several minutes to hours  - UNCONSCIOUS FOR APPROX. 2 HOURS AFTER THE MVA
  • Weakness or numbness in fingers and toes - HAVE TINGLING IN FINGERS AND TOES
  • Loss of coordination - EYE HAND COORDINATION IS HORRIBLE.  I DID A COGNIFIT ONLINE TEST AND I HAVE THE BRAIN OF SOMEONE 10 YEARS OLDER THAN I AM
  • Headache - HAVE MIGRAINES WEEKLY WITH EYE SIGHT PROBLEM (TUNNEL VISION)
  • Nausea or vomiting - SOMETIMES HAVE STOMACH PAIN
  • Fatigue or drowsiness - ALWAYS TIRED NO MATTER HOW MUCH SLEEP I GET
  • Problems with speech - SPEAK SLOWLY, HAVE TROUBLE THINKING OF WORD AND RELATING THEM TO OBJECTS
  • Difficulty sleeping - ALWAYS HAVE TROUBLE FALLING ASLEEP AND STAYING ASLEEP
  • Dizziness or loss of balance - STAND UP TOO FAST AND I GET DIZZY

Cognitive or mental symptoms

  • Profound confusion - HAVE DIFFICULTY UNDERSTANDING/INTERPRETING WHAT SOMEONE IS SAYING
  • Agitation, combativeness or other unusual behavior - HAVE LOST OR LEFT 11 JOBS IN 10 YEARS, I BECOME ANGERED EXTREMELY EASILY 
  • Slurred speech - COULD NOT SPEAK CLEARLY FOR SEVERAL YEARS AFTER THE ACCIDENT
  • Memory or concentration problems - CAN'T REMEMBER LISTS OF THINGS THE WIFE WANTS ME TO GET AT THE GROCERY STORE, SHORT TERM MEMORY IS HORRIBLE
  • Mood changes or mood swings - 2 CIVILIAN DOCTORS, VA C&P PSYCH, MY CIVILIAN PSYCHOLOGIST HAVE DIAGNOSED ME WITH ANXIETY AND DEPRESSION
  • Feeling depressed or anxious - 2 CIVILIAN DOCTORS, VA C&P PSYCH, MY CIVILIAN PSYCHOLOGIST HAVE DIAGNOSED ME WITH ANXIETY AND DEPRESSION
  • Loss of Interest - I GAVE UP ON MANY OF THE HOBBIES I USE TO ENJOY

Sensory symptoms

  • Sensory problems, such as blurred vision, ringing in the ears, a bad taste in the mouth or changes in the ability to smell - VA RATED ME AT 10% FOR TINNITUS, I ALSO HAVE MIGRAINES AND TUNNEL VISION
  • Sensitivity to light or sound - NUMBER ONE REASON I LEAVE JOBS IS THE NOISY WORK ENVIRONMENT WHICH TRIGGERS MIGRAINES

MY QUESTION IS SHOULD I SPEND $1500 OUT OF POCKET TO GET DIAGNOSED WITH A TBI THAT HAPPENED BEFORE THE VA AND DOD EVEN DEFINED WHAT THE SYMPTOMS OF TBI ARE?  I THINK THE VA SHOULD BE RESPONSIBLE FOR THE TESTING.  THE VA ACKNOWLEDGES THAT ACCIDENT HAPPENED, ACKNOWLEDGES I WAS UNCONSCIOUS FOR OVER 1 HOUR BUT CANNOT TEST ME FOR A TBI?

Edited by FC1
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Were you on active duty in 1990 when you had the car accident?

Were you active in 2019 for that MVA?

Little lost on the story but we will figure it out.

 

 

 

 

 

 

I know what you are going through because I am going through the same thing. I do have PTSD from combat. I did try to get serviced connected for TBI because of a vehicle rollover as well and was told by a neuro that I do have TBI but VA still denied it for the same reason that they have denied yours.. If for some reason they do SC it, they will roll it up together with PTSD.

 

Maybe filing for PTSD was not the best option. I probably would have filed for Major Depression Disorder due to what happened and how it impacts your life.

 

My recommendation is to get Veterans Benefit Lawyer which I use Veterans Benefit Law Group and let them fight it for you.Just takes a little time and patience but if you do win, Ching Ching. They will evaluate your case and if they accept it, then its a pretty good chance that you will win. I do not think that you should have to pay out of pocket as I did which costed me thousands of dollars for a DBQ which VA will find another way to deny it.

What is your total rating? if you are close to 100, trust me, its hard to get there but never give up. Keep fighting.

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Let's get back to the basics, here.  You are gonna need documetation of the Caluza elements, which I will explain, below:  

Do you have a copy of your service records and cfile?  Did it show "documentation" of an "in service event" (THE MVA).  Im gonna assume that MVA occurred "while you were in service" but I did not get that from your post for sure.  

You do NOT have to have an "in service diagnosis", but you do need a current diagnosis of tbi.  Check your records for these 3 things, dont rely upon your memory:

1.  Documentation of an "in service event".  Probably the MVA.  Is this contained in your service records?  If not, you may be able to obtain the same by contacting the medical office or provider that administered your care.  Ask them for a copy. 

2.  CURRENT diagnosis.  Did a doctor diagnose you with TBI and did he note that in your records?  If not you will need the same.  If the VA did not/will not provide this current diagnosis, and you have tbi, then you will need an IMO or IME to prove the same.  

3.  Nexus, or doctors opinion that your MVA "at least as likely as not" caused your current diagnosis of TBI.  

      If you get all 3 of these you should win.  If you are lacking any, well you need to get them.  A doctor can examine you and provide a current diagnosis, and he can also supply a nexus statement, but that wont matter unless you have docuemtnation of your trauma event, in other words your MVA.  

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Do NOT let the VA deceive you into thinking you need a tbi diagnosis in service.  That is not the criteria.  

 

Edited by broncovet
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AS BRONCOVET MENTION ABOVE  YOU NEED THOSE THREE THINGS  KNOWN AS THE  ''Caluza elements''        TO WIN THIS CLAIM FOR PTSD.

FC1 Quoted

''The TBI C&P VA doctor reviewed my records from the civilian trauma center and said "You have a Moderate TBI."  The VA rating "specialist" said the opposite.''

Is this civilian Dr  a SPECIALIST WITH TBI?

CHECK OUT THE VA C&P DR  CREDENTIALS TOO.

A SPECIALIST HAS WEIGHT WITH THE VA RATERS THIS CIVILIAN DR   IF THIS HAPPEN WHILE YOU WERE STILL ON ACTIVE SERVICE   IT CAN BE YEARS AGO TOO BUT IT NEEDS TO HAPPEN WHILE YOU WERE IN THE MILITARY   IF NOT  IT WILL BE HARD TO PROVE OTHER WISE, THE SPECIALIST  NEEDS TO NEXUS THIS (TBI)TO THE AUTO ACCIDENT  AND ALSO HE NEEDS TO READ YOUR MILITARY MEDICAL RECORDS

YOUR CLAIM COULD  POSSIBLY GO INTO EQUAPOSE AND LET THE RATER DECIDE....WE NEVER KNOW HOW THESE RATERS WILL DECIDE A CLAIM  BUT MOST WILL GO WITH THE SPECIALIST Dr OPINION.

You also will need a PTSD Diagnose from the VA   THEY WILL ONLY USE A PTSD  DX From the VA ONLY.

You should file a MDD Claim  IF YOU HAVE DEPRESSION  which you more than likely do  and if you can't get in a auto to drive  that could be from your Depression....it will be hard for you to get the PTSD because

''Service connection for post traumatic stress disorder with panic attacks and depression is denied since this condition neither occurred in nor was caused by service. (38 CFR 3.303, 38 CFR 3.304)
Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.
We did not find a link between your medical condition and military service.''   

Edited by Buck52
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It would appear that you are most likely missing or have an inadequate nexus statement, but I have not reviewed your records, so I dont know.  You can review them, however, and see for yourself.  

You may consider "getting help" with your claim, especially given the "profound confusion" you posted you were diagnosed with.  That help can come from at least 4 sources:

1.  You can get professional help such as an attorney who may charge 20 percent of the "retro" you get.  

2.  You may be able to get by with a VSO who does not charge but does not have as good a record as do attorneys.  

3.  There is something called a "non attorney practioner" such as Alex Graham who represents Vets usually for a fee, that does NOT have a law degree.  

4.  A friend or family member may be able to help you, especially with guidance from hadit volunteers.  

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You can hire an attorney and pay them their fee.  It sounds like any VA law firm would love your case.  Or you can do the medical gathering yourself like I did and take it to the VA yourself.  I got 70% tbi (initial claim) for an in service training accident that knocked me out for less than 10 minutes.  After I submitted my outside medical evidence from Dr's. that are well versed in VA claims lingo, I had several C&P's.  3 TBI & 2 PTSD.  The initial TBI C&P was from a Neuro Psyc. with QTC.  2.5 hours worth of testing.  I got agitated with the first guy about the tests.  He said if we aren't thorough this first time, the VA will try to screw you.  That chilled me out and put my trust in him.  He wasn't bullshitting.  He did me right.  The VA put me thru two more TBI C&P's.  Why?  Only thing I can think of is they were looking for a different opinion, or clarifying  things. Maybe they were hoping they would find something to screw me, like the good Doc said.

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I was on active duty in 1990 when the MVA happened.  In 2011 I retired and filed for my left shoulder which was given 0%.  It took 23 months for the VA to even get me a hearing test and i pretty much just gave up expecting the VA to help.

In 2016 at the request of my wife I sought help from a civilian doctor who diagnosed me with PTSD due to having problems maintaining employment due to anger issues and dealing with stupid people at work.  In 2019 I refiled for disability with the county VSO because of having PTSD symptoms, tinnitus, memory issues, shoulder, knee and wrist pain.  All injured on active duty. 

Yes the C&P doctor is qualified to conduct TBI exams.  The VA contracted LHI who lists all of the doctor's qualifications.

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