Citation Nr: 1304993 Decision Date: 02/11/13 Archive Date: 02/21/13 DOCKET NO. 09-01 303 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a gastrointestinal disorder and an abdominal aortic aneurysm, to include as secondary to posttraumatic stress disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sara Schinnerer, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1943 to February 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office in Oakland, California. During the course of this appeal, the Veteran moved and is now under the jurisdiction of the VA Regional Office located in Muskogee, Oklahoma (RO). This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The Veteran was afforded a VA examination in December 2010. However, in a April 2011 remand, the Board found that the examination was inadequate for purposes of determining service connection. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this regard, the December 2010 VA examiner rendered a diagnosis of "[gastroesophageal reflux disease]/hiatal hernia." The examiner, however, failed to address whether any of the Veteran's current prescription medications for a service-connected disorder caused or aggravated his gastroesophageal reflux disease or hiatal hernia. Further, the examiner separated "nonservice-connected" alcohol use from the Veteran's alcohol abuse associated with posttraumatic stress disorder, without explanation as to the distinction. Moreover, the examiner did not provide a rationale for any of the opinions rendered. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, the Board remanded the case in April 2011, for the Veteran to be afforded another VA examination. A VA examination in May 2011, diagnosed a history of stomach ulcer and hiatal hernia with a normal exam. The examiner noted that an addendum would be provided once a report of the upper gastrointestinal series and lab tests were associated with the claims file. In the subsequent May 2011 addendum, the examiner indicated that there was no diagnosis of any gastrointestinal disorder. The examiner indicated that since there was no diagnosis of any gastrointestinal disorder, an opinion was not given, as it was not required. Although the May 2011 VA examiner found that the Veteran did not have any current diagnosable gastrointestinal disorder, the requirement for a current disability is satisfied if there is evidence of the disability at any time since the Veteran's claim in August 2005, even if the disability is currently in remission. McClain v. Nicholson, 21 Vet. App. 319 (2008). Accordingly, the case must be remanded in order for the Veteran to be afforded another VA examination to whether any diagnosed gastrointestinal disorder, to include the gastroesophageal reflux disease and hiatal hernia diagnosed during the December 2010 VA examination is due to service; due to or aggravated by the Veteran's service-connected posttraumatic stress disorder, to include alcohol abuse; and due to or aggravated by any medications prescribed pursuant to a service-connected disability. Moreover, the evidence of record shows that as recently as September 2012, the Veteran was being followed by his family practitioner, T. M., M.D., for gastrointestinal symptoms. VA examiners indicate that the Veteran's gastrointestinal symptoms are being treated with Omeprazole. The last evidence received by Dr. M. was a letter dated in December 2010, that was received in January 2011. Accordingly, Dr. M.'s records should be obtained and associated with the evidence of record. See 38 C.F.R. § 3.159(c)(1). Finally, in a March 2012 statement, the Veteran informed VA that he had moved to a different apartment within the same building. The RO sent the November 2012 supplemental statement of the case to the Veteran's prior address. Thus, as the November 2012 supplemental statement of the case may not have been correctly delivered to the Veteran, the RO must provide the Veteran with a copy of this document and all further documents to his current address as mandated by due process. Accordingly, the case is remanded for the following actions: 1. The RO must take notice of the Veteran's current address and provide the Veteran a copy of the November 2012 supplemental statement of the case at his current address of record. 2. The RO must attempt to obtain all relevant treatment records from Dr. M. from December 2010 to the present. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 3. The Veteran must be afforded a VA examination to determine whether any diagnosed gastrointestinal disorder is related to his military service or to a service-connected disorder. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether any currently diagnosed gastrointestinal disorder, to include the December 2010 diagnosis of gastroesophageal reflux disease and hiatal hernia is related to the Veteran's active military service; due to or aggravated by the Veteran's service-connected PTSD, to include alcohol abuse; or due to or aggravated by any medications prescribed pursuant to a service-connected disability. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 4. The RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of his claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained that shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 5. The examination report must be reviewed by the RO to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 6. Once the above actions have been completed, the RO must readjudicate the Veteran's claim on appeal, taking into consideration any newly acquired evidence. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).