Citation Nr: 1759976 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 07-24 217A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to service connection for tremor of the right and left hands, to include as due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Brennae L. Brooks, Associate Counsel INTRODUCTION The Veteran served on active duty for training from April 1982 to October 1982, and had periods of active duty from May 1988 to October 1988, January 1991 to April 1991, and March 2003 to February 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in August 2006 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing in January 2009 before a Veterans Law Judge who is no longer employed at the Board. As such, he subsequently requested a hearing before another Veterans Law Judge. In February 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. Transcripts of both hearings have been associated with the record. In April 2009, March 2010, March 2011, January 2014, April 2015, and May 2017, the Board remanded the case for additional development and it now returns for further appellate review. The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action is required. REMAND Although the Board regrets the additional delay, another remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). The Veteran contends that he experiences a tremor disorder of the hands due to exposure to environmental hazards, to include Sarin gas, cyclosarin, and sand flea repellant, during his service in the Southwest Asia Theater of Operations from January 1991 to April 1991 and from June 2003 to February 2004. In this regard, in the May 2017 remand, the Board requested a VA examiner to provide opinions to numerous inquiries. Specifically, a medical opinion was needed to address (i) whether the Veteran's tremors constituted a clinical diagnosis or symptoms of a medically undiagnosed illness; (ii) if such were a diagnosed disorder, whether the disorder was congenital or acquired; and (iii) whether the disorder was caused and/or aggravated by the Veteran's active duty service from January 1991 to April 1991 and/or from March 2003 to February 2004. Thereafter, the Veteran was afforded a VA examination in July 2017 so as to address such inquiries. While the examiner offered adequate opinions as to most inquiries, the Board finds that a remand is necessary in order to obtain an addendum opinion as to whether the Veteran's diagnosed tremor disorder was caused or aggravated by his active duty service from January 1991 to April 1991 and/or from March 2003 to February 2004. Regarding whether there is clear and unmistakable evidence that the Veteran's tremor disorder preexisted his periods of active duty from January 1991 to April 1991 and/or March 2003 to February 2004, the examiner opined that he had no information regarding evidence of tremors prior to the Veteran's period of active duty; however, he did not specify which period of active duty he was addressing. Additionally, he concluded that it was less likely than not that the Veteran's tremor disorder was directly related to his military service, including his in-service exposure to environmental or chemical hazards coincident with his service in Southwest Asia. As rationale, he stated that medical literature does not support the likelihood of exacerbation of essential tremors by any known environmental hazard. However, as the examiner did not explicitly address the Board's inquiries with regard to each period of active service, or take into account the lay and medical evidence reflecting complaints of tremors since the Veteran's period of active duty from January 1991 to April 1991, an addendum opinion addressing such matters is necessary to decide the claim. Accordingly, the case is REMANDED for the following action: 1. Return the record to the VA examiner who conducted the Veteran's July 2017 tremors examination. The record and a copy of this Remand must be made available to the examiner. If the July 2017 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, please address the following inquires: (A) Is there clear and unmistakable evidence that the Veteran's tremor disorder pre-existed his period of active duty service from January 1991 to April 1991? (i) If so, is there is clear and unmistakable evidence that such pre-existing disorder did not undergo an increase in the underlying pathology during such period of service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran's disorder, was such increase clearly and unmistakably due to the natural progress of the disease? (ii) If not, is it at least as likely as not (i.e., a 50 percent or greater probability) that the disorder is directly related to such period of service, including the Veteran's in-service exposure to environmental or chemical hazards coincident with his service in Southwest Asia (i.e., Sarin gas, cyclosarin, and sand flea repellant). (B) Is there clear and unmistakable evidence that the Veteran's tremor disorder pre-existed his period of active duty service from March 2003 to February 2004. (i) If so, is there is clear and unmistakable evidence that such pre-existing disorder did not undergo an increase in the underlying pathology during such period of service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran's disorder, was such increase clearly and unmistakably due to the natural progress of the disease? (ii) If not, is it at least as likely as not (i.e., a 50 percent or greater probability) that the disorder is directly related to such period of service, including the Veteran's in-service exposure to environmental or chemical hazards coincident with his service in Southwest Asia (i.e., Sarin gas, cyclosarin, and sand flea repellant). In offering such opinions, the examiner should consider the entirety of the record, to specifically include the Veteran's and his wife's statements that he has had tremors since his period of active duty from January 1991 to April 1991; the notation of tremors as early as June 14, 1995, in which fine hand tremors with no limitations were observed on a Periodic Report of Medical Examination; a diagnosis of benign familial tremors in August 2001; a February 9, 2004, Post-Deployment Medical Evaluation reflecting the Veteran's report of numbness and tingling in his hands or feet; and subsequent diagnoses of tremors in March 2006 and October 2006. A rationale for any opinion offered should be provided. 2. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter 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 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. §§ 5109B, 7112 (2012). _________________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 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 your appeal. 38 C.F.R. § 20.1100(b) (2017).