Letters to Medical Experts

1
Letters to Medical Experts
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Steps to Take Before Seeking a Medical Opinion

• Obtain a current diagnosis
• Submit evidence that shows it is possible (even
  better as likely as not or more likely than
  not) that the alleged in-service incident or
  event occurred
• Research the current condition
• Interview the claimant/veteran and help the
  claimant prepare a statement detailing the
  symptoms noted by the veteran that the advocate
  and the veteran believe are related to the
  current disability
• Interview family members and friends of the
  veteran who can provide additional lay statements
  regarding the history of the veterans symptoms
• Obtain a copy of the veterans claims file

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Steps to Take Before Seeking a Medical Opinion

• Prepare Cover Letter for Medical Expert Letter
  Must
• explain the medical issue to resolve,
• note that a copy of the claims file is enclosed,
• summarize relevant facts and tab them in the
  C-file,
• ask medical expert to state that he/she reviewed
  C-file in their response,
• stress that the standard of proof is the benefit
  of the doubt (as likely as not)
• ask detailed questions that usually can be
  answered with a yes or no,
• invite medical expert to call you if any
  questions, and
• (if relevant) notify the medical expert where to
  send their bill

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Advocacy Tip

• Make it easy for the medical expert to agree with
  the veterans contentions.
• Provide expert with continuity of symptomatology
  (usually w/ lay statements)
• Show expert medical texts and other statements
  from experts that support linkage between the
  veterans current condition and service

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Sample Letter to Medical Expert

• All letters should contain
• OPENING PARAGRAPH--introduces veteran, gives
  info on veterans condition, indicates why
  doctor should provide a favorable medical
  opinion summarize standard of proof that is
  favorable to veteran.
• SUMMARY OF FACTS LAW-- Give details of
  service specify injuries/problems in service
  symptoms in service and post-service, treatment,
  other medical opinions, and other relevant info
• QUESTION FOR EXPERTbe as precise as possible
• CLOSING PARAGRAPH--thank expert, ask expert to
  indicate review of claims file, provide
  contact info

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Sample Letter to Medical Expert

• Mr. Jones served July 1969 to January 1972
• Wounded in action in 1971
• Several times treated for painful feet.
  Bilateral foot complaints variously diagnosed
  as bilateral trench feet, bilateral pes cavus,
  bilateral pes planus.
• Separation examination showed no musculoskeletal
  defects.
• Vet claims while in combat hurt his back
  several times, causing significant pain. Did
  not seek treatment.
• After discharge, veteran had almost continuous
  pain in lower back, still did not seek
  treatment. Lay statements from family say he is
  a stoic.
• In 1989, diagnosed with spinal stenosis. MRI
  provided impression of severe spinal stenosis.
• In April 1989, Dr. Black indicated that vet had
  back problems for years in 8/88 developed
  significant pain. Veteran advised to consider
  surgery, but did not have surgery.

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Sample Letter to Medical Expert

• SUMMARIZE RELEVANT LAWS
• Explain benefit of the doubt
• Therefore, I will phrase my questions to you so
  that you can respond to Is it as likely as
  not.
• Explain combat veteran advantage
• In Mr. Joness case, his statements about what
  happened to him during service all are connected
  to incidents that occurred when he was engaged in
  combat with the enemy. Therefore, for the
  purposes of your medical opinion, please accept
  his statements as proven facts.
• Explain that preexisting injury presumed to
  have been aggravated by service in cases where
  there is an increase in disability during
  service, unless specific finding that increase
  due to natural progress of disease.

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Sample Letter to Medical Expert

• QUESTIONS
• Is it as likely as not that current severe
  spinal stenosis is linked to trauma suffered
  in service?
• Assuming a preexisting back condition on entry
  (entry exam noted limited lumbar motion
  tenderness), is it as likely as not that trauma
  to back in service, which resulted in increased
  back symptoms, aggravated preexisting back
  condition, and that back condition that was
  aggravated in service is linked to the current
  back condition?
• SMRs show treatment for pain in feet,
  attributed in service to pes cavus, pes planus,
  and trench foot. Is it as likely as not that
  bilateral foot pain is connected to the current
  back condition?
• Or, is it as likely as not that pain caused by
  SC trenchfoot caused or aggravated back
  condition?

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Sample Letter to Medical Expert

• Thank doctor for assistance.
• Make clear doctor should indicate in letter that
  he/she reviewed the entire claims file.
• Provide contact information in case doctor has
  questions.

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Sample Letter 2 to Medical Expert

• Begins by introducing the veteran, giving brief
  background of case, and why opinion necessary.
  
• Opening includes paragraph that research shows
  that those with mental illnesses more likely to
  smoke.
• Letter introduces the doctor to benefit of the
  doubt and low standard of proof.
• Make clear what Dr.s opinion should contain
• statement that doctor reviewed entire c-file
• Reasons or bases for the doctors conclusions

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Sample Letter 2 to Medical Expert

• The letter also contains a Cautionary Note.
• Please focus only on the psychiatric condition
  for which the veteran was service-connected at
  the time of his death and for the 47 years prior
  to his deaththat is, anxiety disorder with
  depression and conversion symptoms. You said in
  one of your letters that he may have been
  misdiagnosed in the 1950s, and that his real
  service-connected condition might more properly
  be characterized as PTSD. To focus on a
  misdiagnosis that may have occurred about 50
  years ago would probably do more harm than good
  to the claimants case at this point.

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Sample Letter 2 to Medical Expert

• Vet served 1940-1945. In 1950, received SC for
  chronic conversion reaction.
• In 1977, he submitted documents showing he was
  having trouble working. RO denied increased
  rating
• In 1993, vet stated he was worse and could not
  work. 1994 decision increased SC evaluation to
  100 based on TDIU, effective 10/93
• 3/96 RO decision awarded 100 schedular
  evaluation
• Vet died in 1996, due to chronic obstructive
  pulmonary disease due to or as a consequence of
  tobacco and History/of asbestosis.
  Contributing causes were status post MI and
  status post 4-vessel bypass.
• In 9/96, DIC application filed.

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Sample Letter 2 to Medical Expert

• Advocate asked Dr. the following question
• Is it as likely as not, or better, more likely
  than not, that the veterans service-connected
  anxiety condition caused or aggravated (worsened)
  his smoking habit (nicotine addiction). We
  already know from the death certificate that COPD
  was determined to be the primary cause of his
  death, and that tobacco was considered a
  secondary cause. Please explain your answer.
• Advocate instructed Dr. to make her own medical
  determination. Thanked Dr.