Citation Nr: 1330155 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 11-11 570 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for residuals of a head injury, with residual brain aneurysm. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran, J.G. ATTORNEY FOR THE BOARD Rory Reyhan Layne, Associate Counsel INTRODUCTION The Veteran had active service from February 1956 to May 1959. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (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) (2013). The appeal is remanded to the RO via the Appeals Management Center, in Washington, DC. REMAND Review of the Veteran's claims file reflects that he has not been afforded a VA examination addressing the etiology of any residuals of a head injury, to include a brain aneurysm. In disability compensation claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i) (2013); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. The evidence of record reflects that the Veteran has a current diagnosis of a partially thrombosed aneurysm. Service treatment records show that the Veteran was treated after an altercation, in December 1956 for multiple contusions of face. In April 1957, the service treatment records also show the Veteran was treated for a "post traumatic headache." During his May 2013 hearing before the Board, the Veteran testified that while in service a pole fell on his head, he was treated in service for headaches and, thereafter, he continuously experienced headaches. In addition, the Veteran's friend, J.G. testified before the Board that he had known the Veteran for "a long period of time", and that the Veteran had "continuously shared with me the symptoms of the headaches." While there is no medical evidence of record proving a link between the Veteran's aneurysm and his active duty service or a service-connected disorder, the testimony from the Veteran and his friend, reporting continued symptoms of headaches since service discharge, meet the low threshold for VA to provide a medical examination. McLendon, 20 Vet. App. at 83. Thus, the RO should provide the Veteran with a VA examination addressing any residuals of the injury he experienced in service. Additionally, a review of the Veteran's claims file reveals that there are additional private medical treatment records identified by the record that have not been obtained by the RO and associated with the Veteran's claims file. Specifically, in February 2008, and more recently in the April 2011 substantive appeal, the Veteran informed the RO that he had received treatment at the San Antonio Methodist Hospital for his brain aneurysm. However, there is no indication in the claims file that the RO attempted to obtain the identified private treatment records. Thus, the RO should request all of the identified private medical treatment records. Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must attempt to obtain all pertinent records from the San Antonio Methodist Hospital. All attempts to secure this evidence must be documented in the evidence of record 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. 2. The Veteran must be afforded the appropriate VA examination to determine whether any residuals of a head injury, to include, if found, a brain aneurysm and/or a chronic headache disorder, are related to his military service. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The claims file and all electronic records, to include on Virtual VA, must be made available to the examiner, and the examiner must specify in the examination report that these 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 there are any residuals of the Veteran's injuries to the head and face as documented in the service treatment records, to include any currently or previously diagnosed brain aneurysm and headache disorder, or whether any currently or previously diagnosed brain aneurysm and headache disorder are otherwise related to the Veteran's active duty service. A complete rationale for all opinions must be provided. If the examiner cannot provide the 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. 3. The RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the 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 (2013). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained which 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. 4. The VA examination report obtained 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. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claim on appeal must be readjudicated. If the issue on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have 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).