Citation Nr: 1800136 Decision Date: 01/03/18 Archive Date: 01/19/18 DOCKET NO. 16-42 670 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for ischemic heart disease (claimed as a heart condition), claimed as a result of exposure to Agent Orange. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD R.M.K., Counsel INTRODUCTION The Veteran had active service from October 1952 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) from a July 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. Jurisdiction was subsequently transferred to the RO in Winston-Salem, North Carolina. This appeal was processed using the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this case should take into consideration the existence of these records. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Board finds that additional evidentiary development is required before the claim on appeal is adjudicated. The Veteran seeks service connection for a heart condition as he claims it is related to service, to include on the basis of exposure to Agent Orange during service. At the outset, the Board notes that the record indicates that the Veteran is in receipt of Social Security Administration (SSA) benefits. On remand, the AOJ must make as many requests as necessary to obtain the Veteran's SSA records and associate them with the electronic claims file. See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). On remand, the AOJ must also obtain all current VA medical records and any other private medical records the Veteran identifies. See 38 C.F.R. § 3.159. Service treatment records show that the Veteran's heart was found clinically normal on his enlistment examination in October 1952. Service treatment records show that his heart was found clinically abnormal on a May 1961 examination; the notation indicated blowing systolic grade I-II systolic murmur. Medical evidence of records shows onset of ischemic heart disease in 1994. Private treatment records also show a diagnosis of coronary artery disease status-post surgical intervention. Therefore, the Board finds that the Veteran should be afforded an examination to address the nature and etiology of his claimed heart condition. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions.) Finally, remand is required in order to comply with the duty to assist. VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017). In this case, it does not appear that the Veteran has been provided adequate Veterans Claims Assistance Act of 2000 (VCAA) notice for the issue on appeal. Therefore, a remand is necessary to ensure that the Veteran is provided a proper VCAA notice letter. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a VCAA notice letter in connection with his claim for ischemic heart disease (claimed as a heart condition). The letter should (1) inform him of the information and evidence that is necessary to substantiate the merits of the service connection claim; (2) inform him about the information and evidence that VA will seek to provide; and, (3) inform him about the information and evidence he is expected to provide. 2. Request from the SSA any and all records pertinent to the Veteran's claim for Social Security disability benefits as well as medical records relied upon concerning that claim. If the search for such records has negative results, the AOJ should notify the Veteran and place a statement to that effect in the record. 3. Obtain and associate with the record any outstanding VA treatment records; and, with appropriate authorization from the Veteran, any additional outstanding private treatment records identified by him as pertinent to his claim. 4. Then, the Veteran should be afforded a VA examination by an examiner with appropriate expertise to determine if his heart condition is related to his service. The electronic claims file must be provided to and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a complete review of the electronic claims file, the examiner should address the following: a.) diagnose any heart condition the Veteran has had at any point during the appeal period. b.) opine as to whether there is a 50 percent or better probability that the Veteran's heart condition was present during active service or is etiologically related to the Veteran's active service. A complete rationale for all opinions expressed must be provided, to include discussion of the diagnosis of blowing systolic grade I-II systolic murmur in May 1961. 5. Upon completion of the above development and any additional development deemed appropriate, readjudicate the issue on appeal. All applicable laws and regulations should be considered. If the benefit sought on appeal remains denied, the appellant and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. The appellant 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 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). _________________________________________________ MICHAEL A. PAPPAS 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).