Citation Nr: 1326048 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 09-08 188 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for cold injuries of the left upper extremity. 4. Entitlement to service connection for syncope. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tahirih S. Samadani, Counsel INTRODUCTION The Veteran served on active duty from December 1950 to December 1952. The Veteran also served in the United States Army Reserve. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 and November 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio and Montgomery, Alabama, respectively. In April 2013, the Veteran testified at a hearing before the undersigned using video-conferencing technology. A transcript of the proceeding is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND For the reasons that follow the Board finds that the Veteran's claims for service connection must be remanded for further evidentiary development. Private treatment records The Veteran reported that he was treated for hypertension by a private physician in the Alabaster area. The Veteran should be asked to provide these records or provide information to the VA so that the VA can attempt to obtain these records. VA examinations Under the Veterans Claims Assistance Act of 2000 (VCAA), VA must provide an examination when there is (A) competent evidence of a current disability that (B) may be associated with service, but (C) there is insufficient medical evidence to make a decision on the claim. 38 U.S.C.A. § 5103A(d). Here, February 2009 treatment records from Shelby Baptist Medical Center note a single episode of syncope. During the Board hearing, the Veteran testified that his syncope was due to cold exposure in Korea during is active military service. See Board hearing conducted in April 2013, page 25. In his substantive appeal of December 2011, the Veteran appeared to indicate that he experienced syncope in service. As there is insufficient medical evidence to make a decision on the claim, the Veteran should be afforded a VA examination for his syncope. The Veteran claims that he has cold injuries of the left upper extremity. He testified to numbness in his left elbow and left shoulder. See Board hearing conducted in April 2013, page 16. The Veteran claims that his left upper extremity disorder is related to cold exposure in Korea during his active military service. The Board finds that there is insufficient medical evidence to make a decision on the claim, and the Veteran should be afforded a VA examination for his cold injuries to this left upper extremity. The Board acknowledges that the Veteran was afforded a Cold Injury examination in July 2011, but the examiner did not address the left upper extremity. For this reason, the Board finds that the Veteran should be afforded a new examination. VA treatment records Also, the Veteran reported in November 2007 that he was treated for hypertension at the Birmingham VA medical center from January 1997. However, the earliest VA treatment records associated with the record date from July 2007. The Veteran also testified that he lived in Michigan and was treated at a VA facility in Dearborn. The Veteran should be asked to clarify at which facility he received treatment and the approximate dates of treatment. Service records The claims folder indicates that the Veteran had Army Reserve service apparently from 1952 to 1962. As the original request for service treatment records only requested records from the Veteran's period of active service, the Veteran's complete Reserve medical and personnel records should be requested on remand. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Attempt to obtain through the appropriate channels all service treatment records and service personnel records for the Veteran's service with the United States Army Reserve from 1952 to 1962. All attempts to fulfill this development should be documented in the claims file. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. The Veteran should also be informed that he can submit alternate evidence to supplement the available service treatment records. See M21-1MR, Part III, Subpart iii, Chapter 2, Section E.27.b. 2. Send the Veteran a letter asking him to identify any additional medical treatment he has received for his claimed disabilities. Specifically, the Veteran should be asked to provide or authorize the release of private treatment records related to his treatment for hypertension by a physician in the Alabaster area. He should also be asked to clarify at which VA facility he was treated in Michigan and the approximate dates of treatment. 3. Obtain VA medical treatment records as follows: a. those pertaining to treatment of the Veteran at the Birmingham VA Medical Center dating from January 1997 to July 2007; b. those pertaining to treatment of the Veteran at a VA facility in Michigan for the dates and facility identified by the Veteran in response to step 1; and c. any recent relevant VA treatment records that have not yet been obtained. 4. With respect to steps 2 and 3, if, after making reasonable efforts to obtain named non-VA records the AMC is unable to secure same, or if after continued efforts to obtain federal records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 5. After obtaining any additional records to the extent possible, schedule the Veteran for a VA examination to determine the etiology of his left upper extremity disorder. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination, and the examiner should confirm that such records were available for review. The examiner should answer the following question: Is it at least as likely as not (50 percent or greater likelihood) that any diagnosed left upper extremity disorder began in or is related to his military service, to include as a result of cold exposure therein. [It is noted that service connection for residuals of cold injury to the lower extremities was granted by way of an October 2011 rating decision]. A complete rationale for the opinion should be provided. 6. After obtaining any additional records to the extent possible, schedule the Veteran for a VA examination to determine the etiology of his syncope disorder. The claims file must be reviewed by the examiner and such review must be noted in the examination report or an addendum. The examiner should answer the following question: Is it at least as likely as not (50 percent or greater likelihood) that any diagnosed syncope disorder began in or is related to his military service, to include as a result of cold exposure therein. The examiner's attention is directed to the December 2011 substantive appeal in which the Veteran appears to indicate that he had symptoms in service. A complete rationale for the opinion must be provided. A complete rationale for each opinion should be provided. 7. Thereafter, review the claims folder to ensure that the foregoing requested development has been completed. In particular, review the examination report to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 8. Following the completion of the foregoing, and after undertaking any other development it deems necessary, review all the evidence of record [to include any and all relevant evidence added to the Veteran's electronic claims folder] and readjudicate his claims for service connection. If any remain denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. 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).