Citation Nr: 1600214 Decision Date: 01/05/16 Archive Date: 01/12/16 DOCKET NO. 15-01 547 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for varicose veins. 2. Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. E. Miller, Associate Counsel INTRODUCTION The appellant is a Veteran who had active service in the U.S. Army from September 1954 to September 1956. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2014 decision of the Houston, Texas, Regional Office (RO) which denied service connection for varicose veins and post-traumatic stress disorder (PTSD). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the AOJ. VA will notify the appellant if further action is required. REMAND The Veteran contends that service connection for her varicose veins is warranted. She alleges that they were caused by having to stand on tile floors in combat boots while in-service at Brooke Army Medical Center at Fort Sam Houston, Texas. She also contends that service connection for an acquired psychiatric disorder is warranted because, while there, she was detailed to the burn unit where she took care of patients and prepared deceased veterans for transportation to the morgue. In a March 2014 statement from the Veteran describing her varicose veins symptoms, she stated that she is receiving social security benefits. The evidence considered by the Social Security Administration (SSA) in granting the Veteran's claim is not of record. VA's duty to assist the Veteran includes an obligation to obtain the records from the SSA. Masors v. Derwinski, 2 Vet. App. 181, 187-188 (1992). No service treatment records and limited service personnel records have been associated with the claims file. In a February 2014 response to a Request for Information, it was noted that if the record is missing due to the 1973 fire at the National Personnel Record Center (NPRC). It stated that no service treatment records, reports of the Office of the Surgeon General of the Army, or service personnel records are available. In a case in which a veteran's service records are unavailable through no fault of her own, there is a heightened obligation for VA to assist her in the development of her claim and to provide reasons or bases for any adverse decision rendered without these records. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991); see also Moore v. Derwinski, 1 Vet. App. 401 (1991) (holding that a heightened duty to assist a veteran in developing facts pertaining to her claim in a case in which service medical records are presumed destroyed includes the obligation to search for alternative records). The Veteran does not contend that she was treated at any facility in-service for an acquired psychiatric disorder or varicose veins. Therefore, there are no further records requests to be made. The record reflects that the Veteran had service at Brooke Army Medical Center at Fort Sam Houston, Texas, as a clerk. A statement from Y. Kuo, M.D., states that the Veteran "has severe varicose veins in [her] legs. She is unable to stand for [a] long time or to push [a] wheelchair due to leg pain." The Veteran has not been afforded a VA examination for her varicose veins or an acquired psychiatric disorder. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that she provide information as to all treatment of varicose veins and an acquired psychiatric disorder, including the names and addresses of all health care providers whose records have not already been provided to VA. Upon receipt of the requested information and the appropriate releases, the RO should contact all identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the Veteran, not already of record, for incorporation into the record. 2. Contact the SSA and request that it provide documentation of the Veteran's award of disability benefits and copies of all records developed in association with the decision for incorporation into the record. 3. Schedule the Veteran for a VA vascular examination to obtain an opinion as to the nature and etiology of her varicose veins. All indicated tests and studies should be accomplished and the findings reported in detail. The examiner should advance an opinion as whether it is as likely as not (i.e., probability of 50 percent or more) that the Veteran's varicose veins had their onset during active service; are etiologically-related to her service at Brooke Army Medical Center; and/or otherwise originated during active service. All relevant medical records must be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions should be provided. 4. Schedule the Veteran for a VA psychiatric examination to obtain an opinion as to the nature and etiology of an acquired psychiatric disorder. All indicated tests and studies should be accomplished and the findings reported in detail. The examiner should advance an opinion as whether it is as likely as not (i.e., probability of 50 percent or more) that any identified acquired psychiatric disorder had its onset during active service; is etiologically-related to the Veteran's service at Brooke Army Medical Center; and/or otherwise originated during active service. All relevant medical records must be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions should be provided. 5. Then readjudicate the issue on appeal. If any benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC) which addresses all relevant actions taken on the Veteran's claim for benefits, to include a summary of the evidence considered, since the issuance of the statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran 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). _________________________________________________ MATTHEW D. TENNER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board is appealable to the Court. 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) (2015).