Citation Nr: 18140265 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 11-27 754 DATE: October 2, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REASONS FOR REMAND The Veteran served on active duty from March 1970 to May 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision. In his October 2011 VA Form 9 Substantive Appeal, the Veteran requested to appear at a hearing before a member of the Board. In subsequent October 2011 written correspondence, however, the Veteran withdrew the request for a Board hearing. The Board considers the hearing request withdrawn at this time. See 38 C.F.R. § 20.704 (e). In September 2009, the Veteran applied for service connection for PTSD. The United States Court of Appeal for Veterans Claims (Court) has held that when a Veteran claims service connection, she or he is not claiming service connection for a specific diagnosis, but for his or her symptoms regardless of the diagnosis, and the claim encompasses the underlying condition, regardless of diagnosis. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). Applying the Court’s ruling in Clemons, the issue on appeal encompasses service connection for any currently diagnosed psychiatric disability. In October 2017, a VA examination for PTSD noted that the Veteran did not have or identify any mental health issues or treatment while he was in-service. However, a review of the record showed that a January 1972 service treatment record (STR) stated the Veteran was having mental difficulties. An April 1972 STR showed the Veteran to have been referred to a therapy group. Additionally, a May 1972 STR showed that the Veteran had been interviewed at a Naval Hospital psychiatric clinic. A separate May 1972 STR showed the Veteran to have undergone a course of medication and support psychotherapy. Thus, the Board finds that the October 2017 VA examination is inadequate for adjudication purposes. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). When an examination is inadequate, the Board must remand the case for further development. Bowling v. Principi, 15 Vet. App. 1 (2001), 38 C.F.R. § 4.2. The matter is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA medical examination to determine the nature and etiology of any diagnosed acquired psychiatric disability, including PTSD, by an examiner who has not previously examined the Veteran. The claims file, including a copy of this Remand, must be made available to the examiner. All necessary tests and studies should be accomplished. The examiner should: (a.) Identify any diagnosed acquired psychiatric disability, including PTSD; (b.) If there is a diagnosis of an acquired psychiatric disability, including PTSD, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such a disorder had onset in service or within one year following separation from service, or was causally related to service. The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The Veteran’s lay assertions as to onset and continuity and symptomatology should be recorded and considered. The examiner is asked to specifically address the January, April, and May 1972 STRs which indicate the Veteran had mental health treatment while in-service, the Veteran’s December 2012 Decision Review Officer hearing testimony, and the Veteran’s August 2018 statement in support of claim. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. (Continued on the next page)   If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Parrish, Associate Counsel