Citation Nr: 1336209 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 08-12 824 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety disorder, and depression. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and B.G. ATTORNEY FOR THE BOARD C. Wendell, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 to July 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In that decision, the RO denied service connection for an acquired psychiatric disorder, to include PTSD, anxiety disorder, and depression. The Veteran and B.G. testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in June 2013. A transcript of the hearing is contained in the Virtual VA file associated with the Veteran's claim. The Veteran submitted additional evidence in support of his claim at his June 2013 Travel Board hearing, along with a waiver of review of such evidence by the agency of original jurisdiction. As such, the Board may properly consider such evidence at this time. See 38 C.F.R. §§ 20.800, 20.1304(c) (2013). The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in Virtual VA and Veterans Benefits Management System (VBMS) to ensure consideration of the totality of the evidence. 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 The claim must be remanded for further development and an addendum opinion. VA's duty to assist a claimant includes the procurement of relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The record indicates that the Veteran has been receiving Social Security disability benefits since 2003. However, the Social Security records have not been associated with the claims file and there is no indication the records are unavailable. As it is unclear from the record what the Veteran is receiving disability benefits for, it cannot be said that the records are irrelevant or that they would not help to substantiate the Veteran's claim. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Thus, the Board must remand the claim so these records can be obtained and associated with the claims file. Both the Veteran and B.G. have stated that the Veteran received a Purple Heart for injuries he sustained while serving in Vietnam. The Veteran's personnel records and DD 214 do not indicate a Purple Heart was awarded; however, the fact that he was wounded is noted in his personnel records, and the Veteran is in receipt of service-connected benefits for shell fragment wounds received in Vietnam. Thus, his combat service is not in question. The Board must remand for an addendum VA medical opinion. Once VA provides an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The July 2011 examiner noted that during his VA examination that the Veteran did not endorse any PTSD symptoms, and opined that the Veteran's depression was due to the residuals of his 2003 cerebrovascular accident and not service. However, during the June 2013 hearing, the Veteran and B.G. stated that the Veteran experienced depression long prior to his cerebrovascular accident, and that he has had symptoms such as irritability, nightmares, sleeplessness, and intrusive thoughts since service. In light of this testimony, the claim must be remanded for an addendum opinion to ensure the opinion has an accurate factual basis. While on remand, efforts must be made to obtain any relevant VA treatment records from June 2011 forward, to include records from Columbus and Dothan CBOCs and Tuskegee VA Medical Center (VAMC). Appropriate efforts should be made to obtain any medical records identified and authorized for release by the Veteran. Accordingly, the case is REMANDED for the following action: 1. Contact the Social Security Administration and obtain a complete copy of any adjudication and the records underlying any adjudication for disability benefits. All efforts to obtain Social Security records should be fully documented, and a negative response must be provided if records are not available. 2. Obtain any VA treatment records from June 2011 forward, to include records from Columbus and Dothan CBOCs and Tuskegee VAMC. Request that the Veteran identify and authorize for release any other relevant medical records, and then make appropriate efforts to obtain any records so identified. All actions to obtain these records should be documented. If the records cannot be located or do not exist, a memorandum of unavailability should be associated with the claims file, and the Veteran should be notified and given an opportunity to provide the records, if able. 3. After undertaking the development listed above to the extent possible, obtain an addendum opinion from the examiner who provided the July 2011 VA opinion or another appropriate medical professional. The claims file must be made available and reviewed by the reviewer, to include relevant electronic records. A note that it was reviewed should be included in the opinion. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. After reviewing the claims file and the associated electronic files, the reviewer should answer the following questions: a) Does the Veteran currently have PTSD according to the diagnostic criteria in the DSM-IV? Note that the Veteran is in receipt of service-connected benefits for shell fragment wounds received in Vietnam. Thus, his combat service is not in question. b) If yes, is it at least as likely as not (a fifty percent probability or greater) that the Veteran's PTSD was incurred or aggravated in service? c) If the Veteran does not currently have PTSD under the DSM-IV, does the Veteran have any other current acquired psychiatric disabilities, to include depression and anxiety disorder? d) If yes, is it at least as likely as not (a fifty percent probability or greater) that the disability was incurred or aggravated in service? Review of the entire file is required; however, attention is invited to the Veteran's and his sister's June 2013 hearing testimony regarding his symptoms prior to the 2003 stroke. The Veteran and his sister are competent to testify as to symptoms that they personally observed. The Board finds this testimony to be credible. A detailed rationale supporting the reviewer's opinion should be provided. If the reviewer feels that the requested opinion cannot be rendered without resorting to speculation, the reviewer must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the reviewer (i.e. additional facts are required, or the reviewer does not have the needed knowledge or training). Jones, 23 Vet. App. 382. In forming the opinion, the reviewer should consider the Veteran's lay statements and the hearing testimony. The reviewer is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the reviewer's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. Thereafter, readjudicate the issue on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period in which to respond. The Veteran has the right to submit additional evidence and argument on the matter 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). _________________________________________________ BETHANY L. BUCK 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).