Citation Nr: 18142603 Decision Date: 10/16/18 Archive Date: 10/16/18 DOCKET NO. 16-02 539 DATE: October 16, 2018 ORDER Entitlement to an effective date prior to October 20, 2014, for the grant of service connection for a left ankle sprain is denied. REMANDED Entitlement to service connection for a sleep disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to an initial rating in excess of 10 percent for a left ankle sprain is remanded. Entitlement to an initial rating in excess of 10 percent for residuals of a right distal fibula fracture (right ankle disability) is remanded. FINDING OF FACT The Veteran’s original claim for service connection for a left ankle disability was received by VA on October 20, 2014; there were no formal or informal claims prior to that date. CONCLUSION OF LAW The criteria for an effective date prior to October 20, 2014, for the grant of service connection for a left ankle sprain have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.151, 3.155 (2014), 3.400 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from January 1980 to January 1983. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an effective date prior to October 20, 2014, for the grant of service connection for a left ankle sprain The effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). If the claim for service connection is received within one year of a veteran’s discharge from service, the effective date of an award of service connection will be the day following discharge from service or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1) (2012); 38 C.F.R. § 3.400(b)(2) (2018). The effective date of an award based on a claim reopened after final adjudication shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400(q)(2), (r) (2018). On October 20, 2014 VA received a VA Form 21-526EZ requesting service connection for a left ankle condition. A January 2016 rating decision granted service connection for a left ankle sprain with an effective date of October 20, 2014. After thoroughly reviewing the record, the Board finds that prior to October 20, 2014, there were no pending and unadjudicated claims for service connection for a left ankle disability. While the Veteran has requested an earlier effective date, he has not indicated why an earlier effective date is warranted. Specifically, neither he nor his attorney have identified any claim for service connection for a left ankle condition prior to October 20, 2014. As there was no pending and unadjudicated claim for service connection for a left ankle condition, the earliest possible effective date for entitlement to service connection for a left ankle sprain is the date of receipt of the Veteran’s original claim for service connection, which is October 20, 2014. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). As discussed below, the Board is remanding the Veteran’s other claims to obtain updated medical evidence. However, for the reasons set forth above, this evidence cannot establish entitlement to an earlier effective date for a left ankle sprain as a matter of law. Thus, the Veteran’s claims for earlier effective date for the grant of service connection for a left ankle sprain must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a sleep disorder is remanded. 2. Entitlement to service connection for hypertension is remanded. 3. Entitlement to service connection for headaches is remanded. 4. Entitlement to service connection for an acquired psychiatric disorder is remanded. 5. Entitlement to an initial rating in excess of 10 percent for a left ankle sprain is remanded. 6. Entitlement to an initial rating in excess of 10 percent for residuals of a right distal fibula fracture (right ankle disability) is remanded. A September 14, 2001 VA treatment record notes that the Veteran reported being evaluated by a psychiatrist during his military service. The Veteran's service treatment records do not contain any psychiatric clinical records. As psychiatric service treatment records may be kept separately from other service treatment records, a request for any psychiatric treatment records should be made. The record also reflects that the Veteran has receives for Social Security Administration(SSA) disability benefits. Specifically, a June 25, 2015 VA treatment record indicates that the Veteran received “SSDI.” To date, the Veteran’s SSA records have not been requested or otherwise associated with the claims file. Accordingly, such records should be requested on remand. See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992). The record also indicates that there are outstanding private treatment records. VA treatment records note that the Veteran had previously received private mental health treatment from Delta consultants, Good Hope, High Point, and unidentified facilities in North Carolina, San Francisco and Seattle. To date, these records have not been requested or otherwise obtained. On remand, reasonable efforts should be made to obtain them. The Veteran was last examined for his ankles in December 2014. An updated examination would aid in evaluating the Veteran’s claims. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, including Delta consultants, Good Hope, High Point, and the unidentified psychiatric facilities in North Carolina, San Francisco and Seattle. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Request all in-service psychiatric / counseling treatment records through official sources. If additional information is needed from the Veteran to request such records, the Veteran should be asked to provide it. All efforts to obtain such records should be documented in the claims file. If the requested records do not exist or cannot be obtained, the Veteran should be notified of such. 3. Request all documents pertaining to any application by the Veteran for SSA disability benefits, including the medical records considered in deciding the claim. All efforts to obtain such records should be documented in the claims file. If the requested records do not exist or cannot be obtained, the Veteran should be notified of such. 4. After records development is completed to the extent possible, the Veteran should be afforded a VA mental disorders examination to determine the nature of any acquired psychiatric disorder and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current any acquired psychiatric disorder, other than personality disorders, arose during service or is otherwise related to service. In so opining, the examiner should address the Veteran’s December 1979 Report of Medical History noting frequent trouble sleeping and “depression or excessive worry,” his in-service disciplinary infractions, and the February 14, 2008 treatment record noting that the Veteran had a long history of bipolar disorder and had received mental health treatment “since he was a kid.” A complete rationale for all opinions expressed should be provided. 5. Schedule the Veteran for a VA ankle examination to determine the current severity of his right and left ankle disabilities. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. All symptomatology associated with the Veteran’s right and left ankle disabilities should be reported. A complete rationale for all opinions expressed should be provided. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Anderson