Question,
Jim,
I found the following case and thought it interesting enough to share with you. This is a service connection of a condition SECONDARY to another condition.
Citation Nr: 9912713
Decision Date: 05/10/99 Archive Date: 05/21/99
DOCKET NO. 96-48 793A ) DATE )
On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine
THE ISSUE
Entitlement to service connection for angina as a result of service-connected post-traumatic stress disorder (PTSD).
REPRESENTATION
Appellant represented by: The American Legion
INTRODUCTION
The veteran served on active duty from May 1951 to September 1953.
This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 1996 rating decision that denied service connection for angina as secondary to PTSD.
The Board also notes that the veteran had previously perfected an appeal of a claim for an increased rating for PTSD, but withdrew his appeal of this issue in January 1996. Consequently, the only issue now before the Board is the claim of service connection for angina as a result of PTSD.
FINDING OF FACT
The veteran experiences angina on occasion as a consequence of his PTSD.
CONCLUSION OF LAW
The veteran has angina that is the result of already service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.310 (1998).
REASONS AND BASES FOR FINDING AND CONCLUSION
Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1998). Service connection is also warranted where the evidence shows that a disability has been caused or aggravated by an already service-connected disability. 38 C.F.R. § 3.310 (1998); Allen v. Brown, 7 Vet. App. 439 (1995).
In the veteran's case, he is service connected for PTSD. As early as May 1996 clinical treatment records have included assessments that the veteran has angina which is associated with emotional factors. A May 1996 record entry referred to "stress related angina," and a July 1996 report prepared by a VA cardiologist includes an assessment of "stable angina [that] tends to be aggravated by PTSD." In September 1996, a record showed the veteran's complaint of his having angina with emotional stress. It was felt that he appeared well stabilized from a cardiac perspective.
On examination by VA in October 1996, arteriosclerotic heart disease was diagnosed. The examiner specifically opined that he could not say that PTSD definitely caused or aggravated arteriosclerotic heart disease. At an October 1996 mental status examination, the VA examiner indicated that PTSD was not the proximate cause of angina. It was reported that angina was brought on by several factors. However, in the veteran's case, angina was sometimes brought on at night by PTSD nightmares.
Finally, a VA examiner reported in July 1998 that there was no clear-cut correlation between symptoms of chest pressure and nightmares due to PTSD. The examiner specifically opined that PTSD was not aggravating the veteran's angina; however, it was reported that PTSD might be the cause of occasional anginal episodes.
The evidence described above tends to show that PTSD indeed has an effect on angina. While it appears that PTSD was not the proximate cause of the veteran's angina, it has played a role, even to the extent causing certain episodes of angina. In short, even the medical examiners who definitively opined that PTSD had not caused angina have conceded that certain episodes of angina are brought about by PTSD. This is a clear indication that PTSD has made the veteran's angina worse. If nothing else, the PTSD causes increased frequency of angina. Because angina is a symptom, namely pain, and because the above-mentioned evidence strongly suggests that this symptom is increased with PTSD-related nightmares, the Board finds that service connection is warranted for this worsened problem. Allen, supra.
ORDER
Service connection is warranted for PTSD-related angina.
MARK F. HALSEY
Member, Board of Veterans' Appeals
Answer:
Thanks for sharing. I don't recall seeing this one before. I get a fair amount of mail asking if it is possible to service connect heart and vascular disease to PTSD as a secondary condition. I always reply that as a rule, it isn't possible to make the connection.
The case presented is unusual in that a VA physician opined that the angina might be related to PTSD. Thus the physician created a nexus. That the physician did that was no doubt an error on his part and a poor choice of words. If you had asked 100 physicians "Is chest pain (angina) caused by PTSD?" 99 of them will firmly answer "No". And that is correct. Studies that have attempted to make the link between PTSD and heart disease seem to always run aground because the study group individuals have other risk factors that contribute to the development of heart disease. To directly correlate PTSD and vascular disease would require a study population who were free of tobacco, free of high cholesterol and so on.
Once the words are charted into the medical record, the decision maker has no room to argue. The word of the MD almost always ends the discussion. This case does not necessarily establish precedence and any veteran following that would still have to find a physician who knows his case to utter similar language...not always easy to do.
I personally believe that PTSD is a contributor to vascular disease. I think it's related to the chemical responses of the body from what we used to call the "Fight or Flight Reflex". The release of adrenalin and similar chemistry is powerful and sets up an inflammatory response at a cellular level that triggers an avalanche of bad stuff over time.
And then there are the social issues...drugs, smoking, lack of sleep, etc. that are intertwined and all together you have a human who is predisposed to illnesses including vascular issues.
Jim Strickland's Mailbag: Volume #71 for 2008
NOTE: Letters in my mailbag are reprinted just as they come to me. Spelling and grammar are left as is and only small corrections are made to improve readability, ensure anonymity or delete expletives that may offend some readers. This is not legal advice. You should always seek the advice of an attorney who is qualified in Veterans' law before you make any decisions about your own benefits.
11.13.08
Question:
Jim,
I am a Vietnam Vet. I am 20% disabled from wounds. I was recently turned down for additional disability. I filed for kidney cancer, had kidney removed, stage 4 renal failure, high blood presure, enlarged prostate. I filed it on being exposed to Agent Orange. What would be my changes of winning it on appeal? Would I just be wasting a lawyer's time, plus my time to. I read all your articles and trust the advice that you give. Thank you.
Answer:
I recently helped a vet win an agent orange kidney cancer fight.
I'd like for you to do some homework before we start. Go to my benefits guide (VA Benefits Guide ( http://tinyurl.com/5wxapm ) and read up on nexus letters. You'll need one. After you have read that and understand it, we will move to find a reasonable physician who will review your records (for a fee) and if the doctor agrees, write a letter that states that it is more likely than not that the kidney cancer was caused by exposure to AO.
I am currently working with a company that provides medical legal expertise to insurance companies, lawyers, court systems and so on. Once we have secured the nexus letter, we then carefully submit the appeal back to your regional office.
This is commonly thought of as a "direct cause" rather than a "presumptive" approach to proving that a condition is related to an event.
This will be considerable work and worth it.
Question:
Jim,
my father was granted aide and attendance a few years back due to lossing his sight he was granted the benefit, now he has received a bill for 41,000.00 for over payment. along with my father being totally blind so is my mother. they live in their own home, but they need lots of assistance. there is no explanation of what or why the overpayment. can you direct me to what you are allowed to put down as monthly expences, rides to and from appt, grocery, and daily needs. in home care, yard care, household repairs, we have kept this from them as not to add stress to their lives. he receive ssi 1091.00 mom ssi 472.00 per month. tried to call the number but my sister after many tries, then finally getting a person, who indicated they couldn’t given the information needed mostly surrounding how this happened. we have 30 days to appeal which isnt much time. they live in the west, is there someone you can refer my sister to for assisting in this matter? thank you so much and for all those you continue to help
Answer:
I don't know of anyone reliable to refer you to. These cases are notoriously difficult to resolve. Most veterans representatives (VFW, DAV, etc.) don't have a clue what to do, lawyers have no incentive to take it on. The VA can be brutal in collection efforts.
(If I'm wrong about VSOs or lawyers who are skilled and willing to assist a veteran with a recoupment action, please write to tell me how wrong I am. I'd like to add your name to the list.)
The only hope I can offer you is that I will assist you but you must be responsible for doing the actual labor of getting various tasks accomplished.
Here is how I work...
I do not ever represent veterans. I act as a coach or guide to the veteran or a family member. I offer a way to get the goal accomplished through the completion of a structured series of tasks...mostly writing and mailing letters. The letters that I write are very detailed and based on my experience and knowledge of the system. There are certain rules that if followed correctly can be used to defeat or lessen actions by VA.
There are no promises. You're in luck as this is very early in the action where we have a chance to help. Once the dominoes begin to fall, it's almost impossible to stop them.
I do not charge for my services. I do this voluntarily out of a sense of commitment to my veteran brothers and sisters. I don't accept gifts or donations. I do ask that my instructions be followed precisely. If my directions aren't carried out to the letter, I'm wasting my time and I'm very busy.
This isn't particularly difficult but I need to know I am working with someone who won't flake out on me and disappear.
Our plan would be simple. I would like to see the letter from VA. I accept only scanned documents in a PDF or JPG format, no faxes or paper mail.
Then we send a letter to whoever originated the notice from VA. We tie up any action by demanding a hearing and invoking other appeal rights. That buys some time to plan the next action. We have to determine exactly what went wrong and try to blame it on them.
During all this we formulate an appeal to the Committee on Waivers and Adjustments to try have it all forgiven because of his poor health.
It is like a chess game and actions need to begin quickly. Once they begin recoupment, it's nearly impossible to reverse.
