Citation Nr: 1724705 Decision Date: 06/29/17 Archive Date: 07/10/17 DOCKET NO. 15-36 269 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Parsons, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1987 through November 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in February 2017. A transcript is of record. In August 2016, the Veteran submitted a VA 21-0966 Intent to File a Claim for Compensation and/or Pension. It does not appear the Agency of Original Jurisdiction (AOJ) ever responded to this request, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016). The appeal is REMANDED to the AOJ. VA will notify the appellant if further action is required. REMAND The Veteran has claimed, among other stressors, that his current PTSD is related to an in-service event during which he reported to a disturbance while on security patrol. This event is well documented. See e.g. Department of the Navy Commendation Medal award for heroic achievement in the face of grave personal danger to himself in November 1989; service treatment records documenting treatment of minor injuries in November 1989; and The Mirror article reporting the event dated August 1990. The Veteran's DD 214 indicates he was an aviation electronics technician from November 1987 through November 1991 and does not list any foreign service. However, as will be discussed further below, it has been frequently noted in his VA treatment records that he served in Kosovo, Honduras, and in combat in Desert Storm. While the Veteran points to diagnoses of PTSD in his records and feels these support his claim, each of these diagnoses are contained in reports that have inaccuracies about the extent and nature of his service. As none of the examiners who have diagnosed PTSD have relied on accurate facts, their conclusions that he has PTSD are not entirely persuasive. First, there are several references to PTSD in his VA treatment records. However, those records also note he served from 1987 through 2002 and was reactivated from 2003 to 2005 as an instructor at Coronado. They also reference him as having combat service in Desert Storm. There is no evidence in the Veteran's military personnel file to support any of these claimed periods of foreign service or any service subsequent to November 1991. The Veteran should provide details and documentation of any periods of service after November 1991 in order for an adjudication to be made on a complete and accurate record. Second, in November 2011, the Veteran underwent a PTSD evaluation conducted by a private psychologist. The private psychologist noted the Veteran served four years as a Master at Arms and also received anti-terrorism training with the Navy Seals; this service is not verified by the Veteran's military personnel records. The Veteran reported continued PTSD symptoms about his previous military experiences; however, the psychologist does not note which "previous military experiences" caused his symptoms. As the psychologist relied on an inaccurate account of military service (being a member of an antiterrorism unit with the Navy Seals) and did not establish a clear nexus between the Veteran's PTSD and his only verified stressor, this report is not entirely persuasive. Third, the Veteran was afforded a VA examination in January 2013. The examiner noted the Veteran provided security both stateside and in Kosovo and Honduras and also noted he supported DEA operations. This is, again, unsupported by any records currently in the file. The Veteran denied ever being in Kosovo during his February 2017 Board hearing. The examiner opined that the Veteran did not meet the DSM criteria for PTSD, his nightmares were not clearly related to his military service because he was employed as a bail bondsman where he routinely worked at night with potentially violent suspects, and his sleep disturbance was due to alcohol abuse and a long history of working at night. The examiner noted the Veteran's verified stressor in a single sentence: "Veteran once had to subdue a violent suspect while serving as a security officer and sustained a human bite to the left hand." The examiner's emphasis on the Veteran's occupational history and mere cursory note of his verified stressor is misplaced. During his February 2017 hearing, the Veteran clarified that the nature of his work was to answer a cell phone regardless of the time of day, which was often at night, and he only assisted as an additional driver when a person needed to be retrieved from several states away. As the VA examination inaccurately notes the Veteran's service and places undue weight on his post-service occupation, the Board does not find it persuasive. As the medical nexus statements of record appear to be based upon several factual inaccuracies, particularly inaccurate accounts of the Veteran's service, the opinions have little probative value. The VA outpatient records refer to the Veteran as a "CPO" - presumably Chief Petty Officer - and the 2011 private report refers to him as a "Master at Arms." Again, neither of these ranks are supported by the current record, which shows him being discharged in 1991 as an E3. If he has any documents supporting these ranks, he should provide them. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter requesting that he provide details and documentation to verify any active duty overseas service and/or any reserves service subsequent to his separation from active duty in November 1991. If he has any records confirming the various service he has claimed to medical professionals (antiterrorism unit with the Navy Seals, working with the DEA, combat in Desert Storm, and/or service in Kosovo or Honduras, service until 2002 and then as an instructor at Coronado from 2003-05), he must provide it. If he has any documents showing he was a Chief Petty Officer or Master at Arms, he should submit those as well. 2. Obtain and associate with the claims file all relevant VA treatment records from the Bay Pines VAMC and all associated clinics from March 2015 through the present. 3. Only after the above development has been completed, to the extent possible, the Veteran should be afforded a VA psychiatric examination with an appropriate specialist or specialists to address the causation and etiology of his currently diagnosed PTSD. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such a review was accomplished. The examiner's attention is drawn to the verified stressor described in the citation the Veteran received in 1989 and as described in his 2017 testimony. The examiner is asked to provide the following opinion: Is it is at least as likely as not (50 percent probability or greater) that the Veteran has PTSD that is related to his verified in-service stressor as opposed to any other non-service related event. The examiner should not rely on any unverified reports the Veteran served in combat or had foreign service, but limit evaluation solely to the verified stressor. All opinions are to be accompanied by a detailed rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. The AOJ should then readjudicate the claim. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided a supplemental statement of the case. 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 2014). _________________________________________________ MICHELLE L. KANE 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) (2016).