Citation Nr: 1800167 Decision Date: 01/03/18 Archive Date: 01/19/18 DOCKET NO. 14-14 992 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, including posttraumatic stress disorder (PTSD), bipolar disorder, mood disorder, to include whether new and material evidence has been presented to reopen the claim. 2. Entitlement to service connection for migraine headaches with dizziness, to include whether new and material evidence has been presented to reopen the claim. 3. Entitlement to service connection for depression, to include whether new and material evidence has been received to reopen the claim. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Dominic Jones, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1990 to November 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In December 2016, the Board remanded the case to schedule a Board hearing. The Veteran testified before the Board in June 2017. DECISION As each of the three service connection claims were previously denied prior to this present appeal, the Board will first address whether the claims should be reopened prior to remanding for additional development. PTSD By a November 2007 rating decision, the Veteran's claim of service connection for PTSD was most recently denied. She was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in February 2010. No new evidence or notice of disagreement was received by VA within one year of the issuance of the November 2007 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for PTSD is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also September 2010 VA examination (highlighting specific PTSD stressor). Migraine Headaches By a May 2004 rating decision, the Veteran's claim of service connection for migraine headaches was denied. Although the headaches issue was erroneously mitted from the decision, it was included in the notification letter for the decision. This letter notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in February 2010. No new evidence or notice of disagreement was received by VA within one year of the issuance of the May 2004 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for migraine headaches is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also June 2017 Board hearing (doctors have told her that her headaches are related to military service). Depression By a July 1999 rating decision, the Veteran's claim of service connection for depression was denied. She was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in February 2010. Other psychiatric disorder claims were received but they were considered distinct claims. No new evidence or notice of disagreement was received by VA within one year of the issuance of the July 2009 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for depression is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also October 2002 VA treatment note (indicating that the Veteran had depression). ORDER New and material evidence having been presented, the claim to reopen service connection for a psychiatric disorder, including PTSD, bipolar disorder, mood disorder is allowed; to this limited extent, the appeal is granted. New and material evidence having been presented, the claim to reopen service connection for migraine headaches is allowed; to this limited extent, the appeal is granted. New and material evidence having been presented, the claim to reopen service connection for migraine headaches is allowed; to this limited extent, the appeal is granted. REMAND Psychiatric Disorder Claims At various times, the Veteran has claimed entitlement to service connection for PTSD, depression, mood disorder, and bipolar disorder. With regard to the PTSD claim specifically, the Veteran has provided details regarding several stressors. In an October 2003 statement, the Veteran described an incident during Operation Desert Storm in January 1991 where she was awoken in the night by a superior officer to "red alert status" and she stepped out of her tent and artillery "shells were lighting up the sky." In the same document, the Veteran then described an instance in Kuwait where her support battalion was flanked by tanks. Yet another incident described in this statement involved her battalion being given a SCUD alert wherein a missile was destroyed so close that she and others had to inject themselves "with the injection kit and put on full mop gear." Still another incident involved the Veteran losing her way during a sand storm and wandering out of her camp wherein she feared being captured by the enemy. A statement received in December 2006 elaborated further on the earlier-described January 1991 incident. In another December 2006 statement in support of service connection for PTSD, the Veteran described another incident from January 1991 where she was awoken and told her unit had to move quickly and she could not get out of her sleeping bag. She described yelling for help and eventually needing someone to cut her sleeping bag open. Her assignment during this time was the 15th FSB 1st Cavalry Division. She noted she was assigned to the unit from September 1990 to November 1991. A March 2007 letter from a VA psychologist noted the Veteran had a diagnosis of PTSD. The Veteran received a VA examination for PTSD in September 2010. However, her Axis I diagnosis was of "Bipolar I Disorder." The criteria for a diagnosis of PTSD were considered no to be met. Nonetheless, no opinion was provided as to whether this psychiatric condition was incurred in service. The Board finds additional development is warranted for the psychiatric disorder claims. First, the RO should attempt to verify each of the stressors the Veteran has described in her various statements. The Veteran has submitted several throughout the appeal period. Next, a new VA examination should be scheduled in order for an examiner to provide a diagnosis for the Veteran's psychiatric conditions. The examiner should reconcile the previous psychiatric diagnoses of record. If the Veteran is diagnosed with PTSD, the examiner should opine whether such PTSD was incurred in service and identify any stressors. For any psychiatric diagnosis other than PTSD, the examiner should also opine whether these psychiatric disabilities were incurred in service. Migraine Headaches with Dizziness The Veteran contends her migraine headaches began in service. She received a VA examination for this claimed condition in May 1999. The examiner provided an impression of chronic headaches, probably vascular type migraine headaches. The examiner further noted that the Veteran reported that she got dizziness and a spinning sensation with the headaches, and that the dizziness "could be a part of [the] migraine headache." However, the examiner did not opine whether such headaches were incurred in service. In her report of medical history in July 1991 for redeployment, the Veteran checked "yes" to frequent or severe headaches. This provides an indication that the headaches of which the Veteran now complains began during service, and as such another VA examination is warranted to opine whether the present migraines with dizziness were incurred in service. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Accordingly, these issues are REMANDED for the following actions: 1. Attempt to verify the Veteran's stressors as set forth in the remand section above. 2. Schedule the Veteran for a VA psychiatric examination by an appropriate medical professional. The entire claims file must be reviewed by examiner. Any necessary testing should be conducted. The examiner is to determine whether the Veteran meets the criteria for a diagnosis of any psychiatric disorder. A diagnosis of PTSD must be ruled in or excluded. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any currently diagnosed psychiatric disorder had its onset during service or is otherwise causally related to service. If a diagnosis of PTSD is made, the examiner should identify the underlying stressors. A complete rationale should be provided for any opinion reached. 3. Schedule the Veteran for a VA examination by an appropriate medical professional in connection with her claim for migraine headaches. The entire claims file must be reviewed by examiner. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the migraine headaches with dizziness had its onset during service or is otherwise causally related to service. A complete rationale should be provided for any opinion reached. 4. Finally, readjudicate the claims on appeal on the merits. If the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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. ______________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs