Citation Nr: 1749972 Decision Date: 11/03/17 Archive Date: 11/13/17 DOCKET NO. 13-35 660 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona ISSUES 1. Entitlement to service connection for residuals of a head injury. 2. Entitlement to service connection for an acquired psychiatric disorder to include as secondary to residuals of a head injury. REPRESENTATION Appellant represented by: Disabled American Veterans WINTESSES AT HEARING ON APPEAL The Veteran, Ms. L.J., and Mr. R.R. ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty from August 1978 to March 1980. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In November 2016, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing at the RO in Phoenix, Arizona. A transcript of the proceeding has been associated with the claims file. In light of the medical evidence of record and the Veteran's statements, and in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has recharacterized the Veteran's claim for service connection for a major depressive disorder more broadly as a claim of entitlement to service connection for an acquired psychiatric disorder. The issue of entitlement to special monthly comenpensation (SMC) based on the need for aid and attendance or by reason of being housebound has been raised by the record. See Form 21-2680, May 2017. The issue is referred to the AOJ for appropriate action. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND A. Residuals of a Head Injury The Veteran served on active duty from August 1978 to March 1980. He claims that he has residuals of a head injury due to a fall down stairs during his active service. See, e.g., Claim, July 2009; Board hearing transcript, November 2016. Service treatment records dated August 20, 1979, show that the Veteran fell down one flight of stairs three days prior (around August 17, 1979), injured his head, hand, and knee, and was taken by ambulance to the Army Hospital in Heidelberg, Germany (USAH Heidelberg). See STRs at p.83 and 100 of 101. The service treatment records in the file show he returned to the USAH Heidelberg outpatient clinic three days after the fall (on August 20, 1979) with complaints of knee pain. Post-service, the Veteran's records from Banner Health in the claims file include a problem list showing a June 2014 diagnosis of a closed head injury, noted as resolved, albeit not entirely clear whether the diagnosis represents a history of the in-service head injury, as opposed to a more recent head injury or a diagnosis of present residuals of a head injury. See PTRs, received January 2016 at p.50 of 604. The underlying June 2014 Banner Health treatment record relating to the June 2014 diagnosis of a closed head injury is not associated with the claims file. Therefore, this matter should be remanded to obtain any outstanding private treatment records from Banner Health dated in June 2014. The Veteran testified at the Board hearing that he was hospitalized after the fall injury in service. As shown above, the August 1979 service treatment records show the Veteran was taken to the USAH Heidelberg by ambulance, and returned three days later with knee complaints. The Veteran's inpatient clinical records from the Army Hospital in Heidelberg, however, are not associated with the claims file. Therefore, the Board finds that the claim should be remanded so that any outstanding inpatient clinical records from the USAH Heidelberg dated in August 1979 may be associated with the claims file. Also, the Veteran has not been afforded a VA examination relating to the claimed residuals of a head injury. As shown above, the service treatment records document a head injury in service, and his recent Banner private treatment records show a diagnosed closed head injury, albeit the Board again notes that it is not clear whether that diagnosis represents a history of a head injury as opposed to a diagnosis of present residuals of a head injury. The Board also acknowledges lay statements received in December 2011 from the Veteran's family members and friends, including but not limited to his son and sister, in which they reported observing symptoms including memory loss. In light of the above, the Board finds that the low threshold requirement for a VA examination has been met, and the matter should be remanded to afford the Veteran a VA examination. B. Acquired Psychiatric Disorder The Veteran claims that he has had an acquired psychiatric disorder, to include a major depressive disorder, since service. In the alternative, he alleges he has an acquired psychiatric disorder as secondary to his residuals of a head injury. See, e.g., Claim, July 2009; Form 21-4142, September 2009. The Veteran's service treatment records do not show any psychiatric complaints or treatment. Post-service, the treatment records show the Veteran has received intermittent psychiatric treatment since 1992. See, e.g., VA treatment record, July 1992 (received November 1992); PTRs, Maricopa Medical and Phoenix South, (1992). A May 2011 letter from Dr J.V. of the People of Color Network (Magellan Health Services; "SMI" program) shows the Veteran was receiving treatment at their Comunidad Clinic location for a major depressive disorder. A more recent June 2017 VA treatment record shows the Veteran reported to a VA clinician that he was receiving treatment for depression through the SMI program at La Frontera. None of the Veteran's mental health treatment records from the People of Color Network Comunidad Clinic dated since September 2009, or from La Frontera, however, are associated with the claims file. The Board also acknowledges that the Veteran recently submitted an April 2015 Form 21-4142 identifying treatment at the People of Color Network from 2006 to present (2015). Therefore, the Board finds this matter should be remanded so that the Veteran's mental health records from the People of Color Network Comunidad Clinic dated since September 2009, and all of his records from the La Frontera facility, may be associated with the claims file. In addition, the Veteran was afforded a February 2013 VA mental health examination, which report shows a diagnosed mood disorder, not otherwise specified. The examiner noted that the Veteran had a history of treatment since the 1990s, but that the exact onset could not be determined. The VA examiner did not, however, address whether the Veteran's mood disorder was related to his documented head injury in service. Therefore, the Board finds this matter should be remanded for a new VA examination to address whether the Veteran's mood disorder, or any other psychiatric disorder, was caused by the Veteran's documented head injury in service. The VA examiner (mental) should also review the VA examination report that is requested in this remand relating to the claimed residuals of the head injury; if any residuals of a head injury are found on that VA examination, the VA mental health examiner should further address any etiological relationship between any diagnosed psychiatric disorder and the diagnosed residuals of a head injury (if any). Accordingly, the case is REMANDED for the following action: 1. Associate with the claims file the Veteran's private treatment records from Banner Health dated in June 2014 relating to the diagnosed closed head injury shown in the problem list (the underlying record of treatment is missing). 2. Associate with the claims file any available inpatient clinical records from the USAH Heidelberg dated in August 1979 (around August 17, 1979) relating to treatment after a fall down stairs. See STRs at p.83 and 100 of 101. 3. Associate with the claims file all of the Veteran's mental health records from the People of Color Network Comunidad Clinic dated since September 2009, and all of his mental health records from La Frontera. 4. After all of the development in paragraphs (1) and (2) has been completed, schedule the Veteran for a VA examination to determine the current nature and the etiology of his claimed residuals of a head injury. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims folder must be provided to the examiner for review in conjunction with the examination. The examiner should clarify whether the Veteran has any residuals of the documented head injury in service in August 1979. Please direct the VA examiner's attention to a) the May 2011 statements from the Veteran's family members showing they report the Veteran experiences memory problems; and b) the December 2014 head CT scan in the Banner Health records in the file (received January 2016 at p.589 of 604). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After all of the development in paragraphs (3) and (4) has been completed, schedule the Veteran for a VA examination to determine the current nature and the etiology of his claimed acquired psychiatric disorder. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims folder must be provided to the examiner for review in conjunction with the examination. For each acquired psychiatric disorder identified by the examiner, the examiner should also indicate whether it is "at least as likely as not" (meaning a likelihood of at least 50 percent) related to the Veteran's active service, including the documented in-service head injury. Please note to the VA examiner that May 2011 statements from the Veteran's family members show they report the Veteran experiences memory problems. Please ask the VA examiner to review the VA examination requested herein relating to the claimed residuals of a head injury. If any present residuals of a head injury were found by that examiner, then the VA mental health examiner should also comment as to whether the claimed acquired psychiatric disorder is caused or aggravated by (permanently made worse by) the residuals of the head injury found on that examination. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Then, readjudicate the appellant's claims. If any claim remains denied, the appellant should be provided a Supplemental Statement of the Case (SSOC), and then the claim(s) should be returned to the Board for further review. The Board intimates no opinion as to the ultimate outcome of the matter that the Board has remanded. The Veteran has the right to submit additional evidence and argument on that matter. 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). _________________________________________________ H. N. SCHWARTZ 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).