Post-Traumatic Stress Disorder: Service Connection without Treatment Records

The VA system can be difficult to navigate, even for those Veterans with straightforward, well documented claims. Post-traumatic stress disorder claims can be some of the hardest to get service connected because the requirements can be difficult to prove. We’ve discussed before the complications involved with verifying a stressor, particularly when it may not have been well documented or related to combat. However, there are other factors which can complicate a claim for post-traumatic stress disorder, specifically when there are no treatment records.

PTSD without Treatment Records

One such complication comes about when the Veteran has never sought treatment for post-traumatic stress disorder. While seeking treatment is not a requirement for a VA claim, it can help “paper the record” to prove elements of the claim. Where a VA examiner sits down with a Veteran for an hour or so (often far less), treatment records can document months’ or years’ worth of symptoms.

Why can this be problematic? What do treatment records really show when it comes to VA claims? For one thing, treatment records can show a diagnosis if the VA does not offer an exam. Also, the Veteran may have understated his or her symptoms to the VA examiner, which treatment records can contradict. We’ll address each of these scenarios below, and how to deal with them.

While a diagnosis in the record is not a guarantee of service connection, it does provide a leg up in the process. Since we’re talking about claims for which the stressor is not at issue, having both a conceded stressor and a diagnosis can go a long way toward getting a claim service connected.

If a Veteran has never sought treatment for post-traumatic stress disorder, they are obviously not going to have a diagnosis on file. Other than starting treatment in preparation for filing the claim, a Veteran can do a few things to mitigate the issue, assuming the VA does not offer a favorable exam (i.e., either the VA does not offer an examination, or the examiner does not find a diagnosis).

Statement of Symptoms

Treatment records can help paint a picture of an overall disability. Mental health professionals can draw out the Veteran’s thoughts and feelings, and many times treatment will reveal complications previously unknown to the Veteran. Perhaps they did not realize their drinking was a problem or did not acknowledge their reasoning for disliking fireworks. Without treatment records, the file will not contain a detailed list of symptoms of post-traumatic stress disorder.

If there are no treatment records, a Veteran can instead compile a list of symptoms they experience themselves. This can be difficult for many Veterans who prefer not to talk about their symptoms. Minimization of symptoms is a frequent coping mechanism to keep from having to talk about what they’re feeling, which can be problematic for both reporting symptoms to an examiner and for writing them down.

The good news is a buddy statement can come from a spouse or family members who know the Veteran well and can speak to their observations of the Veteran’s behavior and symptoms. Submitting a detailed account of the symptoms with the claim may increase the chances of getting a thorough VA examination. For Veterans who tend to minimize their symptoms or who prefer not to talk about their emotions, this list can make a huge difference.

Private Medical Opinion

Another way in which treatment records can obviously help a Veteran is by providing a definite exam. Since Veterans are not doctors, they cannot submit their claim with a self-diagnosis and expect to be service connected. At best, unless they decide to take action to obtain an alternative, their symptoms will get them an examination through the VA.

The alternative would be to obtain a private professional medical opinion. As simple as that sounds, it can be very stressful to seek out a professional to provide a private examination and give their opinion about a diagnosis. However, this offers the Veteran an opportunity to have a longer, more detailed conversation with their examiner than usually offered by the VA. Particularly if the Veteran has problems with minimizing their symptoms, this longer timeframe can help pull their story out.

Assuming the private examiner provides their assessment in the correct format and they are qualified to diagnose post-traumatic stress disorder, their evaluation can be submitted to the VA as proof of a diagnosis. However, a second and just-as-beneficial use of private examiners is the Veteran does not have to submit the examination report. If the Veteran is not comfortable with a private examiner and does not report all of their symptoms due to their discomfort, they don’t have to submit the resulting report to the VA and they can try again with another examiner with whom they feel more comfortable.

VA Disability Lawyers

At Berry Law, our team of dedicated VA disability lawyers are committed to helping Veterans appeal unfavorable VA decisions and receive the disability compensation they are entitled to. If you would like to appeal a decision by the VA, please contact our team today to schedule a free case evaluation.