Citation Nr: 1800655 Decision Date: 01/05/18 Archive Date: 01/19/18 DOCKET NO. 16-19 140 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and psychological insomnia. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. Giaquinto, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1966 to March 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The Veteran initially filed claims to establish entitlement to service connection for PTSD and entitlement to service connection for insomnia, secondary to PTSD. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Id. at 5. In light of the Court's decision in Clemons and the diagnoses of record, the Board has expanded the Veteran's claims to include direct service connection for all psychiatric disorders, to include PTSD and psychological insomnia, and the issues have been recharacterized as stated on the title page. This will provide the most favorable review of the Veteran's claims, in keeping with the Court's holding in Clemons. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND In January 2015, the Veteran underwent a VA examination for PTSD. At that time, the examiner concluded that the Veteran did not have a diagnosis of PTSD. The examiner did note that under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the Veteran had a diagnosed mental disorder identified as insomnia. The examiner reported the Veteran's claims that his insomnia disability was related to nightmares of his experiences during military service in Vietnam, but did not opine as to whether it was causally related to the Veteran's service. In this connection, the Veteran's representative specifically argued in a December 5, 2017 brief that the issue of entitlement so service-connection for insomnia should be reviewed on a direct basis, as well as a secondary basis, and requested that the Veteran be examined again so that all his psychiatric disabilities can be assessed. As noted above, the Board has expanded this claim under Clemons to include all diagnosed psychiatric disorders. Accordingly, a new examination is necessary to identify exactly what diagnosed psychiatric disorders the Veteran suffers from, and whether any psychiatric disorder, to include insomnia, is etiologically related to active service. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain copies of the complete updated VA clinical and private records of all evaluations and treatment the Veteran received for psychiatric disorders. As needed, signed release forms for private records should be obtained. All requests for records and responses must be associated with the claims folder. 2. Thereafter, schedule the Veteran for a VA mental disorders examination to determine the existence and etiology of any psychiatric disorder found to be present, to include insomnia. The claims folder, including a copy of this remand, must be provided to the examiner for review of pertinent documents therein, and the examination report should reflect such review was accomplished. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the examination report. If PTSD is diagnosed, the examiner should indicate the stressors upon which the diagnosis is based. For any psychiatric disorder that is diagnosed, to include psychological insomnia, the examiner should explain whether it is at least as likely as not (50 percent or greater probability) that such disorder is etiologically related to the Veteran's active duty service, to include the claimed stressors the Veteran experienced during service in the Republic of Vietnam. The examiner should support any conclusions with an explanation of the medical evidence and rationale utilized in coming to that conclusion. 3. After completing the above actions, and any other indicated development, the claim must be readjudicated. If any benefit remains denied, a Supplemental Statement of the Case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. 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). (CONTINUED ON NEXT PAGE) 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). _________________________________________________ V. Chiappetta 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) (2017).