Citation Nr: 1600388 Decision Date: 01/06/16 Archive Date: 01/21/16 DOCKET NO. 14-10 655 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to service connection for a respiratory disability, including chronic obstructive pulmonary disease (COPD) and fibrosis. 2. Entitlement to service connection for residuals of a left leg injury. REPRESENTATION Appellant represented by: Neil B. Riley, Agent WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran served on active duty from February 1964 to February 1966. This case comes before the Board of Veterans' Appeals (the Board) on appeal from an August 2012 rating decision of the Department of Veterans Affairs (VA) Togus Regional Office (RO) Center in Augusta, Maine (hereinafter Agency of Original Jurisdiction). In June 2015, the Veteran testified before the undersigned Veterans Law Judge at a video-conference hearing. A copy of the hearing transcript is associated with the claims folder. The Board has reviewed the Veteran's paper claims folder as well as the record maintained in the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action, on his part, is required. REMAND The Board finds that further AOJ action is necessary prior to any further appellate review. The Veteran seeks to establish his entitlement to service connection for a respiratory disorder. His service treatment records (STRs) reflect a hospitalization in September 1965 for pleural effusion of unknown cause. He alleges that, thereafter, he experienced recurrent episodes of upper respiratory infections. He asserts that his current respiratory disability, which has been diagnosed as COPD with x-ray evidence of basilar fibrosis, results from service including his exposure to Napalm, chemicals, dust and exhaust fumes while serving aboard the U.S.S. Coral Sea. The Veteran was afforded VA examination in July 2012 wherein the examiner recognized current diagnoses of COPD and basilar fibrosis. The examiner opined that the Veteran's respiratory disability was less likely than not related to service based on the rationale that pulmonary function testing (PFT) demonstrated that the Veteran's dyspnea was associated with massive obesity and not intrinsic lung disease. The examiner did not discuss, however, whether the diagnosed COPD and/or basilar fibrosis were first manifested in service or otherwise related to events in service. As such, this examination report must be returned as inadequate for rating purposes. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination with respect to a claim of entitlement to service connection, whether or not statutorily obligated to do so, the duty to assist requires that it be adequate). The Board next notes that the Veteran is seeking service connection for a "left leg injury." See VA Form 21-4138 received in September 2011. In June 2015, the Veteran testified that his left leg was initially injured when being caught underneath the wheel of a helicopter in service with recurrent ankle sprains thereafter. He also reported an additional injury to the left leg as a result of a post-service industrial accident. The Veteran's STRs reflect that, in December 1964, the Veteran's right foot was injured after being run over by a helicopter wheel. He was diagnosed with abrasion and contusion of the right ankle requiring a period of light duty. The available evidence reflects that, post-service in 1968, the Veteran was treated for recurrent right ankle sprains and a left ankle sprain in 1969. Thereafter, he was reportedly treated for an industrial accident involving his left leg complicated by a staphylococcus infection. Notably, a January 1970 AOJ rating decision denied a service connection claim for residuals of right ankle injury. The Veteran has currently initiated and appealed a service connection claim for a left leg injury, but his testimony concerning his left ankle being run over by a helicopter wheel in service conflicts with the STRs which clearly document that the in-service injury involved his right ankle. The Board, therefore, remands this issue for clarification of regarding the benefit sought on appeal. The Board next notes that, at his hearing in June 2015, the Veteran testified to treatment for recurrent respiratory infections at "Mont Creek Medical Center" while stationed at Fort Jackson in the early 1970s. A March 1986 STR reflects that he was advised to see a doctor for respiratory symptoms at Moncrief Hospital. The current name of this military facility is Moncrief Army Community Hospital. See http://www.moncrief.amedd.army.mil/. Additionally, at the hearing, the Veteran reported his willingness to associate with the records any available worker compensation records pertaining to his left leg injury. On remand, the AOJ should also assist the Veteran in obtaining these potentially relevant records. Accordingly, the case is REMANDED for the following action: 1. Conduct a direct search for any available records from Moncrief Army Community Hospital since the Veteran's discharge from active service. 2. Assist the Veteran in obtaining any relevant, available records pertaining to his worker compensation claim for a left leg injury. 3. Advise the Veteran and his representative that the Veteran's testimony concerning his left ankle being run over by a helicopter wheel in service conflicts with his service treatment records documenting that the in-service injury involved his right ankle, and request clarification as to whether he is seeking service connection for a right or left extremity disability as well as clarifying details as to the mechanism of injury and current diagnosis for the claimed lower extremity disability. 4. After receipt of any additional records, and providing adequate time for the Veteran to present additional evidence, forward the Veteran's claims folder to the July 2012 VA examiner for an addendum opinion. The claims folder contents (paper and electronic) must be made available for review. Following review of the claims folder contents, the examiner should provide an addendum opinion as to whether it is at least as likely as not that the Veteran's currently diagnosed COPD and basilar fibrosis had their onset in service, or are otherwise causally related to event(s) in service, to include as a residual of pleural effusion in September 1965 and/or exposure to environmental hazards described as Napalm powder mix, dust, exhaust fumes and various chemicals during his active duty service. In providing this opinion, the VA examiner is requested to accept as true the Veteran's description of his environmental hazards exposure during his June 2015 hearing. However, the examiner may accept or reject the Veteran's testimony of recurrent respiratory infections since active service and rely on the lay description of symptomatology and chronicity which is most consistent with the entirety of the record. If the July 2012 VA examiner is not available, the claims folder should be forwarded to a similarly qualified medical doctor. The Veteran should be scheduled for VA examination if deemed necessary by the examiner. The examiner should be requested to provide opinion to the question posed above. A rationale must be provided for all opinions expressed. If the examiner is unable to provide opinion without resort to speculation, the examiner should explain why a response would be speculative. 5. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and an appropriate period of time to respond. The Veteran has the right to submit additional evidence and argument on the 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 2014). _________________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).