Citation Nr: 1754764 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 13-34 598 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a left leg disability, to include as secondary to a back disability. 3. Entitlement to service connection for an acquired psychiatric disability, to include adjustment disorder with depressed mood. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Hemphill, Associate Counsel INTRODUCTION The Veteran served on active duty in the Army from October 1974 to July 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The appeal was subsequently transferred to St. Petersburg, Florida, which has jurisdiction. In June 2017, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND After a thorough review of the Veteran's record, the Board is not persuaded that VA has fulfilled its duty to assist the Veteran in collection of service hospital records. 38 C.F.R. § 3.159 (c). It is important to note that the military branches of service define service treatment records (STRs) as outpatient treatment records and discharge summaries of inpatient care only. STRs do not include full inpatient treatment records. See VBA Fast letter No. 13-09 (Apr. 26, 2013). A May 1975 STR note indicates that the Veteran was transferred to the Walson Army Hospital in Fort Dix, New Jersey. The record does not contain any evidence that action has been taken to obtain and associate any hospital records from Walson Army Hospital from May 1975 to July 1975, the date of the Veteran's separation. During the June 2017 Board hearing, the Veteran testified that following an in-service fall, he spent two weeks in the hospital and then served on restrictive duty for two months before separation from service in July 1975. As the treatment records from Walson Army Hospital may contain pertinent information regarding the Veteran's reported in-service fall, these records should be obtained and associated with the record. Additionally, there appear to be outstanding post-service VA treatment records. In this regard, the May 2011 VA back examination report notes that the Veteran "moved from Philadelphia VA." The Social Security Administration (SSA) records also contain a signed authorization to disclose health information, in which the Veteran authorized Philadelphia VA to release records. However, the record does not contain any VA treatment records from the Philadelphia VA. Therefore, upon remand, any outstanding VA treatment records from the Philadelphia VA should be obtained and associated with the record. The Board finds that a VA addendum opinion regarding the etiology of the Veteran's back disability should be obtained. The May 2011 VA opinion is inadequate because it is not based on a complete medical record, to include the outstanding Walson Army Hospital records and the SSA records that were subsequently associated with the claims file in March 2014. The Board also finds that the Veteran should be afforded VA examinations to determine the etiology of his left leg disability and his depression as VA examinations have not been conducted. The Veteran indicates that his left leg disability is related to his back disability as it results from the same in-service fall that causes his current back disability. He also indicates that his depression is caused by his physical disabilities. Therefore, upon remand, VA examinations with adequate opinions should be provided. In light of the remand, updated VA treatment records should be also be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records, to include any outstanding VA treatment records from the Philadelphia VAMC. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Obtain all available service hospital records from all periods of verified active duty service have been associated with the claims file. In particular, the Board is interested in hospital (clinical) records from Walson Army Hospital from May 1975 to July 1975, the date of the Veteran's separation. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 3. Upon completion of directives 1-2, schedule the Veteran for VA examinations to determine the etiology of his back and leg disabilities. The claims file, to include a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should note in the examination report that the claims folder and the remand have been reviewed. All indicated tests should be performed and all findings should be reported in detail. The examiner should address the following questions: a) Is it as least as likely as not (50 percent probability or greater) that a back disability manifested during active service or is otherwise causally or etiologically related to his active service? b) Is it at least as likely as not that a left leg disability manifested during active service or is otherwise causally or etiologically related to his active service? c) Is it at least as likely as not that the Veteran's left leg disability is caused by or aggravated by the Veteran's back disability? The examiner should specifically discuss the Veteran's statements regarding an in-service fall which he reports resulted in a back and left leg injury. A complete rationale is requested for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he/she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Upon completion of directives 1-2, schedule the Veteran for a VA psychiatric examination. The claims file, to include a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should note in the examination report that the claims folder and the remand have been reviewed. All indicated tests should be performed and all findings should be reported in detail. The examiner should address the following question: With respect to each acquired psychiatric disability found to be present and/or diagnosed proximate to or during the pendency of the appeal, is it at least as likely as not that the acquired psychiatric disability is caused by or aggravated by the Veteran's back and/or leg disabilities? 5. After completing the above directives and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, readjudicate the Veteran's claims. If any of the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond. The case should be returned to the Board for further appellate consideration, if in order. 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). 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 (2012). _________________________________________________ Nathaniel J. Doan Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (2012), 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 the appeal. 38 C.F.R. § 20.1100(b) (2017).