I put up the first Nexus Bible in 2011 when I switched over here to WordPress. In the intervening years the VA has changed and now we litigate under the newer Appeals Management Act which began February 19th, 2019. By the mid-2020s the Legacy system will have very few outstanding cases.
With that said, I have begun doing what all modern litigators do and purchasing my nexus letters from a reputable outlet. I personally use Mednick Associates. Another outfit called Medconnect is available but for ethical, proprietary information reasons I decline to use them. I’m sure they are capable at what they do but Momma always said if you can’t say something nice about others, keep your mouth shut. I learned that the hard way when I was sued by Wounded Warrior Project back in 2015.
The essence of any nexus letter or Independent Medical Opinion is simple. VA demands three things of us to satisfy the requirements for obtaining service connection. First, you must have had an injury or disease (or risk factor) in service; second, you must have the same disease or injury or secondary conditions from it now; and third, you need an Independent Medical Opinion (IMO) from a reputable source stating that what you had in service is what you have now or was caused by your service. If you rely on VA to provide you with this “nexus” at your c&p examination, you will find out why you need a truly “independent” doctor to perform the exam. VA-contracted examiners are paid to be independent but somehow 85% of their IMOs are not in your favor. Go figure…
With that said, there are what we call presumptives. And boy howdy there are a few of these. The most well-known are the presumptive exposure for Camp LeJeune contaminated water (CLCW) and the Agent Orange herbicide presumptive diseases. We also enjoy the presumption of soundness when we are inducted into the military. In addition, there is the presumption of regularity which doesn’t mean eating Exlax®. Quite simply, the VA operates in a regular manner. If something happens that appears irregular or untoward and you spot it, it means VA cheated, usually. They are prone to do that. Out of giving them the benefit of the doubt, we always presume it was an unintended error and they didn’t mean to.
Direct exposure is another way of proving a claim. If you worked in the motor pool at Camp LeJeune, you would be expected to be exposed to benzene- a common ingredient in both gasoline and the water you were drinking. You can claim exposure on both grounds but again, a doctor has to make this analysis. If you were standing around on the deck of the U.S.S. Minnow watching them bend atoms at Bikini Atoll back in ’48 and have a raging case of the leukemias, yep, that’s a presumptive.
You can always win a direct service connection claim for anything documented in your service department records-like a broken arm or leg. You may not even need a nexus for it. I wouldn’t rush out to buy an IMO until I tried to win on direct.
Who Can Write an IMO?
I have used Doctors, Chiropractors, registered nurses, ARNPs, PA-Cs and any other combo of letters you can come up with. The gold standard is always a doctor. Chiropractors are now respected but they were not in 1989 when I tried it and lost.
There is much controversy about trying to get your own doctor to do this. The first thing you encounter is the word “independent”. Is your doctor giving a truly independent analysis and opinion or is he giving VA what you want him to write? Is he your relative? Your Wife who happens to be an R.N.? See where I’m going with this? If it’s your PA-C brother in law, then the question comes up about whether he knows you. That is an important fact to state. All my IMOs are very particular in stating the doctor has never met my client. I have used a nephew of the client and it was not successful but that was because the guy’s IMO was about two paragraphs long. In combination with about three others, it helped but not as a stand alone product.
When you use your own doctor, he is going to have to state he reviewed you VA claims file. Most doctors I know do not have the time to devote to review 750-2000 pages of your files. If they don’t state they did, VA just says “We read them and his Doctor didn’t so our nexus is more probative because we had all the data. If you see the word “history” used by VA, it means your doctor merely recorded what you told him-your history. VA won’t buy that. You need evidence and good lay statements. Having a doctor merely write what you say happened isn’t going to work unless your STRs show it happened
I include a few IMOs from over the years below to try to illustrate what you need. I still get rejections from VAROs like Little Rock and Jackson, Mississippi but I attribute that to stupidity and a deny-at-all-costs mentality. I always prevail at the BVA with them because they are valid work products and the BVA recognizes it.
The Difference between an IMO and an IME
An IMO has been discussed. An IME is an Independent Medical Evaluation. The BVA will often ask an “independent arbiter” if your IMO is legitimate. It’s the equivalent of an attempt by VA to blow your claim/appeal out of the water. When you get to the BVA on appeal, often the evidence is sketchy. Your IMO is rife with the words possibly and probably. It could honestly be said your claim holds water but is shaky. The Veterans Law Judge in these cases is required to remand it to seek an IME to see if an “independent” doctor might agree or disagree. Yep. 99% are against you. The VA’s idea of an independent reviewer is to go get a hired gun from a VA hospital in Kansas to write an IME about a Vet in North Carolina. Considering who writes the the doctor’s paycheck, it’s almost impossible to get a win this way. Depending on them to be fair is insanity. Thus, we get a truly independent one of our own.
My trick is to file and let VA deny you first. Let them blow hot air about why you are NOT entitled to _____. You can then use your new IMO to specifically address what the VA didn’t. Many times VA simply uses a format and says “Nope. You didn’t have Hepatitis C in service and we don’t see any evidence you suffered anything like it. Denied.” What they know and overlook is that there wasn’t a test for hep C in 1970. Or 1980 or 1990. The first test came online in 1991 and the American Red Cross snapped them all up for a year to protect the blood banks. You were never going to get a test until about 1992 in reality. Further, your liver goes south at a very measured rate so you can measure the degree of deterioration now and extrapolate backwards to find when you were infected. Everyone talks about jetguns but think about what happens now when you go to the dentist compared to the 1968 “Spit that blood into the bowl, Airman.” as they pulled your tooth bare-handed… That was a far greater risk and I’m guessing about 78% of you have your service dental records. Dang-that’s about the only medrecs they managed not to lose.
I see a lot of my fellow Thailand Vets attempt to talk about sticky tools and dead vegetation around the perimeter of the Thai bases we were stationed at. Sorry. All the pictures in the world of dead grass in front of your hootch will not work in court. The same for pictures of guys getting jacked with Jetguns is true. Your pictures will not show the virus on the business end of the nozzle. Saying you stopped at Tan Son Nhut Air Base and deplaned to refuel before continuing to Bangkok has been tried a million times. It helps but you still have to have the Doctor say it.
VA isn’t stupid. As fast as we can come up with ways to defeat their denials, they are busy inventing new ones. You have to stay ahead of their game. Back when Thai Vets began filing for AO shit, VA finally was forced to acknowledge the “tactical herbicides” they used might have been a mite stronger than Roundup™. Now, in spite of what just happened in California where some folks won a big lawsuit over it, it’s still on appeal. You will never get any traction on that. As for Thailand, I’m pretty sure they weren’t using AO strictly. I suspect there was a lot of Agent White and Blue as well. Nevertheless, they are all nasty.
Winning a Thailand claim requires finesse. VA now will allow a presumptive exposure for anyone who was a Security Policeman (AF or Army) or dog handlers. The idea is you have to prove your duties took you into the perimeter areas on a regular basis. The definition of ‘regular’ is debatable. Telephone and cable repairmen get this presumption. I’ve fought a few and won but they are all different. You have to shape the nexus to the Vet. There is no ‘one-size-fits-all’ version.
The worst thing you can say is you worked on Thuds or F4s and they were all “sticky” or had some oily substance on them when they came back from a mission. Get serious. Ranchhand missions which sprayed AO were carefully conducted at about 1,500 to 2,000 feet to avoid too much drift. Fighter pilots don’t get Frag orders taking them into an AO area of operations where spraying is in progress. They don’t do dive bomb passes while dodging C-123s on a spray run over Mu Gia Pass or the Paul Doumer railroad bridge in downtown Hanoi.
You actually harm your claim by making stupid pronouncements about AO. Your win will be because you placed yourself on (or near) the perimeter while taking a smoke break on a regular basis for a year while you were doing airframe repairs on damaged AC-119s and 47s out on the apron or the trim pad at NKP. Even if you claimed there was AO sprayed along the perimeter and you witnessed it, did you stop the spray-rigged deuce and a half and ask the operator what the liquid substance was? Did he actually say “It’s some stinkyass shit called Agent Orange.”? Prove it. Find that guy and have him testify for you 50 years later. See where I’m going? All the buddy letters in the world are worthless unless the Vet says “Johnny and I had to take our smoke breaks across the runway from where we were working on the 123’s and the 130s. The regs said we had to be over 100 yds. away from the A/C. So we’d go over and lean against the perimeter fence and shoot the shit with the Thai sentry over there.” or “We had to walk right down along the perimeter to get to our hootches. They were only about 45 feet away from the front door. The gravel perimeter road we walked on was in between the hootches and the fence.” Shoot. Google a map for your base and try to remember where everything was back then. Throw in you went to “pai teo on Friday/Saturday which entailed walking through…wait for it… the perimeter.
Here’s some examples of winning IMOs I’ve used.
AO in Thailand–Harry Redact AO in Thai
Legal brief for AO in Thailand–Redact VA9 for AO in Thailand
Map Template for bases (Takhli RTAFB)–Takhli titled
Legal brief for AO in Thailand- Filed VA 9 IMO 5-08-2020
For PTSD– PTSD IMO redacted
For Camp LeJeune Water– Camp LeJeune water redacted IMO
For nasal cancer due to AO–AO respiratory IMO redacted
Blindness due to Malaria txment–Malaria IMO redacted
Hepatitis C– HCV IMO redacted
I’ve had a few denied and I send them up on appeal to the BVA. To date, none have been denied. Always remember to make sure your IMO author states s/he has reviewed the VA claims file in writing. This is important. I have seen VA deny based on that alone.
VA uses a gal named Dr. Shirin DaSilva ($137 K/year) out of Nashville/Little Rock to write a lot of their IMOs. She’s worthless but you have to tear apart each one to prove your point. Check this one out.
Filed IMO to BVA 1-8-2018 redacted Dr. DeSilva is the one who mentions polyvinyl chloride which is, as most know, PVC pipe you buy at Home Depot™. I hope all this helps you in your quest for justice.
In the film below, they use jetguns for inoculations. The value of the film is that they do not wipe recruits arms in between injections showing lack of sanitary precautions.