Citation Nr: 1801316 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 14-13 153 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an initial compensable evaluation for malaria. REPRESENTATION Appellant represented by: Michigan Veterans Affairs Agency ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1964 to May 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In that decision, the RO granted service connection for malaria and assigned a noncompensable evaluation effective from April 19, 2012. The Board remanded the case for further development in June 2016. That development was completed, and the case has since been returned to the Board. This appeal was processed using the Veterans Benefits Management System (VBMS) electronic claims processing systems. Accordingly, any future consideration of this Veteran's case should take into account the existence of these electronic records. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran was afforded a VA examination in September 2012 in connection with his claim. The examiner found that Veteran's malaria was inactive, but indicated that he had anemia that was a residual of the disease. However, the Veteran was later afforded an additional VA examination in May 2016, which did not find any symptoms or residuals of inactive malaria. The Veteran has also submitted a July 2016 disability benefits questionnaire (DBQ) indicating that he has had anemia since April 2011. However, that DBQ did not address whether his anemia was a residual of his malaria. Based on the foregoing, the Board finds that an additional VA examination and medical opinion are needed to ascertain the current severity and manifestations of his service-connected malaria, to include any anemia and the findings necessary to evaluate that possible residual. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for his service-connected malaria or any residuals thereof. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate the records with the claims file. The AOJ should also secure any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected malaria and any residuals thereof. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including any treatment records and assertions. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the disability under the rating criteria. In particular, the examiner should state whether the Veteran's malaria is active or inactive and indicate whether there are any residuals of the disease, to include any liver or spleen damage. In so doing, the examiner should specifically discuss whether the Veteran has anemia that is a residual of his service-connected malaria. See September 2012 VA examination report; July 2016 DBQ. If so, he or she should provide the findings necessary to evaluate anemia under the rating criteria (including the hemoglobin levels, and whether he has weakness, easy fatigability, headaches, lightheadedness, shortness of breath, dyspnea on mild exertion, cardiomegaly, tachycardia, syncope, dyspnea at rest, and high output congestive heart failure). A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability is viewed in relation to its history", copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 4. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant 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 (West 2014). _________________________________________________ J.W. ZISSIMOS 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).