Citation Nr: 18143991 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 16-04 946 DATE: October 22, 2018 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a heart disorder, to include coronary artery disease, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for insomnia is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1982 to September 1982 and from February 2003 to October 2003. He also served an extensive period in the National Guard from 1981 to his retirement from the military in 2008. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision by the Department of Veterans Affairs (VA). In January 2016, the Veteran indicated his desire for a hearing before a Decision Review Officer (DRO). However, in October 2018, the Veteran’s representative submitted a written statement waiving the hearing. Therefore, the Board will consider the request to be withdrawn. 1. Entitlement to service connection for bilateral hearing loss is remanded. In a December 2015 rating decision, the Veteran was granted service connection for tinnitus, which represented a full grant of benefits. As such, this issue is no longer on appeal. Evidence indicates that there are outstanding relevant VA and private treatment records. The January 2016 document labeled as a statement of the case lists, among the other evidence reviewed, VA treatment records from January 2004 to September 2015 and private treatment records from Dr. J.C., written in Spanish, from January 2008 to October 2012. Despite the indication that VA reviewed these records before the issuance of the statement of the case, the claims file only contains incomplete records. Specifically, there are VA treatment records from January 2004 to July 2007 and from July 2012 to August 2013. Additionally, there is a June 2008 report by Dr. J.C. written in Spanish. However, there are no other VA treatment records or records from Dr. J.C. These records could contain critical information regarding the claims on appeal. A remand is required to allow VA to associate the records to the claims file, and if necessary, translate them. The June 2008 report must be translated as well. 2. Entitlement to service connection for a heart disorder, to include coronary artery disease, is remanded. 3. Entitlement to service connection for hypertension is remanded. In addition to the above, in a January 2016 statement, the Veteran asserted that he was performing annual training when he suffered from his June 16, 2007 heart attack. However, as it happened so quickly, there was no opportunity to prepare a line of duty report. The Board notes that there is no explanation as to why no line of duty report was not filed later on for such a significant incident. According to his Army National Guard Annual Statement, he received 42 points for inactive duty for training (INACDUTRA) and 15 points for active duty for training (ACDUTRA) during the time from August 2006 to August 2007. However, a June 2007 VA treatment record notes that the Veteran started having chest discomfort “during work.” A later treatment record during that same month indicates that he worked in finance as an assistant manager. Because there is ambiguity as to whether or not the Veteran was performing active or inactive duty for training during the time of his heart attack, the Board finds a remand is necessary to pinpoint the exact dates of ACDUTRA and INACDUTRA during June 2007. Furthermore, the Veteran exhibited what may be symptoms related to his heart disorder and/or hypertension shortly before his October 2003 separation from service. During a September 2003 post-deployment physical examination, the Veteran complained of weakness, muscle aches, and chest pain/pressure, among other symptoms. There is no indication of any medical follow-up for the Veteran’s symptoms. As there is insufficient medical evidence to decide the claim, the Veteran should be afforded a VA examination to determine the nature of his heart disorder and hypertension, and the relationship, if any, of such disabilities to service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 4. Entitlement to service connection for an acquired psychiatric disorder is remanded. 5. Entitlement to service connection for insomnia is remanded. The Veteran is seeking service connection for an acquired psychiatric disorder and insomnia. As referenced above, the claims must be remanded to obtain additional treatment records. Additionally, in a November 2013 statement, he stated that he started to receive medical treatment for his conditions as soon as he was released from active duty in October 2013. VA treatment records may corroborate the Veteran’s statement as the records indicate that the Veteran was diagnosed with both a depressive disorder and insomnia in February 2004, approximately four months after he separated from active duty. However, the Board notes that the Veteran has also been diagnosed with recurrent major depression, anxiety, and an adjustment disorder. As there is insufficient medical evidence to decide the claim, the Veteran should be afforded a VA examination to determine the nature of his acquired psychiatric disorder and insomnia, and the relationship, if any, of such disabilities to service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The matters are REMANDED for the following action: 1. Obtain the Veteran’s outstanding VA treatment records, including from the period from July 2007 to July 2012 and from August 2013 to September 2015. 2. Obtain and associate the Veteran’s treatment records from Dr. J.C. If the records are in Spanish, they should be translated. Additionally, ensure that the June 2008 report by Dr. J.C. that is already associated with the claims file is translated into English. 3. Confirm the exact dates of the Veteran’s ACDUTRA and INACDUTRA during June 2007 in order to evaluate whether he was performing military service when he had his heart attack. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any heart disorder and hypertension. The examiner must opine whether they are at least as likely as not related to an in-service injury, event, or disease, including his symptoms reported in a September 2003 post-deployment report.   5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder and insomnia. The examiner must opine whether they are at least as likely as not related to an in-service injury, event, or disease. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Borman, Associate Counsel