Citation Nr: 1324208 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 05-35 521A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder not otherwise specified and mood disorder. REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney at Law ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service in the United States Air Force from August 1984 to July 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Following a review of the claim by the Board, the Board issued a decision in November 2008 that denied the Veteran's claim for service connection. She was subsequently notified of that action and she appealed to the United States Court of Appeals for Veterans Claims (the Court). A review of the Board's decision ensued and the Court then issued an Order that enacted a previously submitted Joint Motion for Remand. More specifically, the Order vacated the Board's decision of November 2008, and remanded the claim to the Board for additional development. In November 2010 and April 2012, this matter was remanded by the Board for additional development and adjudication. After completion of the requested development, the matter again is before the Board. With respect to the categorization of the issue on appeal, the Board notes that the Court has held that claims for service connection for one psychiatric disorder encompasses claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As such, the Board has characterized this issue as set forth above. The Board has not only reviewed the Veteran's physical claims file, but also the Virtual VA electronic claims file to ensure a total review of the evidence. The appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND The Veteran is seeking entitlement to service connection for an acquired psychiatric disorder. In essence, she claims that her current psychiatric problems began in military service or are otherwise related to her active military service. Despite the extensive procedural development already undertaken, the Board concludes that another remand is required to allow for further development. In a January 2013 statement the Veteran's representative stated "VA has a duty to assist the veteran to obtain pertinent medical records, per the April 2012 Board remand, but has not located those records." She further stated that the Veteran "has maintained her mental health treatment and taken much medication over the years to control her symptomatology." It is noted that the RO asked the appellant to authorize the release of any relevant medical records by way of a July 2012 letter. The record does not reflect that she submitted any authorization forms thereafter that would allow VA to seek records on her behalf. Moreover, during the August 2012 examination, the Veteran reported that she had received mental health treatment since her discharge from the military but could not remember the names of most of the mental health providers. She did, however, state that she had ongoing treatment and medication management by a "Dr. Williams, in Flemming Island, FL." While this clearly is not sufficient information or authorization for VA to seek any outstanding treatment records from this provider, the Board finds it reasonable to conclude that the Veteran could have thought that this notification was a sufficient response to the RO's July 2012 letter. As such, the Board concludes that another letter should be sent to the Veteran specifically identifying "Dr. Williams, in Flemming Island, FL" and requesting full identification of this treatment provider and authorization to obtain records from this provider as well as any other health care providers. In the alternative, as noted above, the Veteran may submit any such records directly to VA. The representative also asserts that the VA examination was inadequate. In the addendum, the examiner stated that he could not give an opinion about the Veteran's lay statements because testing indicated that she was over-reporting psychological symptoms. Therefore, the examiner found it would be resorting to speculation to give an opinion about the accuracy of the Veteran's statements. The representative asserts the opinion is inadequate as the Board has not found the Veteran's statements lack credibility. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide relevant contact information and release form authorization for Dr. Williams of Flemming Island, Florida for all relevant treatment records. In the alternative, the Veteran should be notified that she may provide the private treatment records to VA directly. The Veteran should also be asked to provide or identify any additional relevant treatment records that are not already of record. 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) inform the Veteran that she is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Obtain any additional recent VA treatment records pertaining to the Veteran. If there are no additional records, this should be documented in the record. 3. After steps 1 and 2 are complete, schedule the appellant for a VA psychiatric examination in order to determine the etiology of any psychiatric condition found to be present. The claims file must be provided to the examiner for review and the examination report must indicate the claims file was reviewed. All indicated tests and studies should be conducted and all clinical findings reported in detail. For each diagnosed mental condition, the examiner should provide an opinion as to the etiology of any underlying disorder, disability, or disease. The examiner is asked to state whether it is at least as likely as not (at least a 50/50 percent probability) that any such diagnosed disorder began in service, is a progression of a disorder noted in service, or is otherwise related to the appellant's military service. Please provide a complete explanation for the opinion. The examiner should also state whether the Veteran had psychosis within one year of discharge. Please provide a complete explanation for the opinion. In addition, as the last remand requested information concerning secondary service connection, the examiner should opine whether it is at least as likely as not that the Veteran has a current psychiatric disorder that is due to or caused by the service-connected varicose veins of the lower extremities. Please provide a complete explanation for the opinion. The examiner should opine whether it is at least as likely as not that the Veteran has a current psychiatric disorder that is aggravated (i.e., worsened) beyond the natural progress by the service-connected varicose veins of the lower extremities. Please provide a complete explanation for the opinion. NOTE: The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. In accomplishing this task, the examiner must consider and comment on the Veteran's lay statements regarding the incurrence of her claimed disorder, including her competent report of continuity of symptoms since service. The examiner's attention is directed to VA treatment records showing that during the pendency of this claim the Veteran has been diagnosed as having anxiety disorder (April 2005), mood disorder (July 2005), and depression (July 2006). Depressive disorder was also diagnosed following VA examinations of July 2011 and August 2012. The Board is in essence requesting that the examiner consider and provide opinions concerning the psychiatric symptoms, however diagnosed, that have been manifested by the Veteran during the course of this claim. 4. After the above is complete, readjudicate the Veteran's claim. If a complete grant of the benefits requested is not granted, issue a supplemental statement of the case (SSOC) to the Veteran and her representative, and they should be given an opportunity to respond, before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ S. S. TOTH 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).