A claim for disability benefits can live or die on one medical opinion. In many cases, the VA will rely on findings from Compensation & Pension physicians to reach a decision. However, a disconnect all too often exists between what the veteran expects and what he or she gets. Outcome: claim denied.
So what makes a medical opinion worth the paper that it is written on? Before answering, let me explain what the VA does not consider competent, or expert derived, medical evidence. First, unless your spouse happens to be a physician, he or she cannot answer questions of causation or diagnosis, even if he or she is intimately familiar with your condition. And your cousin who is a dentist cannot provide expert analysis of your heart condition by virtue of his familiarity with a field of medicine. Even a general practitioner’s opinion can often be eclipsed by the findings of a VA expert in a particular field. In order for a medical opinion to matter, it must be both credible and probative.
An opinion is considered credible only if it comes from an expert or, better yet, a qualified source among experts. After clearing that hurdle, it must also be probative, or relevant, to the issue that it addresses. For example, a statement from a neurologist who has reviewed a veteran’s medical history and examined the veteran to arrive at a medical opinion about nerve loss is considered highly persuasive. That is, her opinion is said to be credible and probative.
Sometimes, two medical opinions will arrive at opposing conclusions, and a VA rating specialist must assign weight to each. As mentioned earlier, the best opinions come from physicians who specialize in the medical field surrounding the disability in question. Other important aspects influencing weight include whether the physician reviewed prior clinical records, the physician’s familiarity with the veteran, the degree of specificity and certainty noted in the opinion, and whether the physician’s contact with the veteran was for treatment or substantiation of a claim. Note that an opinion may be overlooked altogether if it materially relies on the veteran’s unsupported history as a premise for the rationale. Also, most importantly, the information contained in the veteran’s claims folder must support the medical conclusion.
I will end with a quick discussion on evidentiary standard. A veteran must prove a claim based on a “preponderance of the evidence.” This means that the evidence as a whole must lean in favor of the veteran by 51 percent or greater, often quantified in a medical opinion by the term “more likely than not.” In many cases, the hardest part about adequately proving a claim is getting the physician to write a favorable opinion when the answers are not very clear. In the end, your claim may only be as good as the opinion on which it is based. ☺