Medical records and medical chart review are among the most important aspects of a VA (Veterans Affairs) claim for disability benefits. There are different types of medical records, each having a specific purpose to serve in a Veterans Affairs claim or appeal. The relevant medical records are those that show that the claimant has a current, diagnosed condition connected with their service, or that their condition has aggravated over the course of time. What evidence is the VA looking for? They need evidence that demonstrates that the claimant has a current physical or mental disability that makes him or her totally unable or less able to perform daily tasks, including meaningful work; and an injury, illness, or event that occurred when the claimant was serving in the military and caused this disability.
Here is a list of the types of medical evidence that should accompany a VA disability claim:
- In-service medical records: These comprise the medical records created while the veteran was enlisted, and will help show the connection between the disability and the veteran’s service. These medical records include sick calls, hospitalizations, enlistment examinations, and discharge examinations. These records can be requested by the veterans themselves, or they can request the VA to obtain the same for them.
- Private medical records: Veterans who are being treated by a private physician for their disability need to provide the VA with their doctor reports, hospitalization records, X-rays, and other diagnostic test results associated with their disability claim. Veterans can request these records directly from their private healthcare providers, which may involve a fee to be paid to the providers for processing the request. The VA will not pay any fees to acquire the medical records. Private medical records help provide information regarding the onset and progression of the claimant’s condition. Also, the VA may not have this information otherwise because the treatment was obtained outside of the VA’s healthcare system.
- VA medical records: These comprise medical records from the VA medical center or facility where the veteran was treated. The VA can get these records directly from the healthcare facility. In case a veteran wants to get these records themselves, a request must be made to the VA Medical Center by submitting VA Form 10-5345a, Individuals’ Request for a Copy of Their Own Health Information. The online portal My HealtheVet also provides access to VA medical records.
- Compensation and pension examination records: The VA may schedule a veteran for a C & P (Compensation and Pension) Exam to determine whether the disability is service-associated or whether the veteran deserves an increased rating for his/her condition. A favorable C & P exam helps substantiate the claim, and if unfavorable, the veteran has the right to submit any additional evidence and argument to rebut the examiner’s findings.
- Medical opinion: Apart from the relevant medical records, a medical opinion obtained from a treating physician regarding the veteran’s disability and how it was caused by his military service, would be helpful to substantiate the disability claim.
In a VA claim, medical evidence may not be required in the following rare instances.
- The veteran developed a long-lasting, chronic illness within one year of discharge
- The illness was caused by contact with hazardous substances or toxic chemicals
- The illness was caused by the veteran’s time as a prisoner of war.
Medical records and medical records analysis can help demonstrate the symptoms and the severity of the veteran’s condition. The veteran must be prompt in reporting the worsening symptoms and the severity of his or her condition to their treating doctors so that the doctors can notate those worsening symptoms. This will help achieve an increased rating for the disability. For disability attorneys, medical records services become very relevant when developing a VA disability case. These help evaluate the medical records, organize them according to relevance, list out the clinical findings, medical opinions, and lab results and establish the types of disabilities diagnosed. With a good understanding of the medical aspects of the case, attorneys can develop their case well and represent the veteran in case the disability claim is denied.