Citation Nr: 18146981 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 16-26 968 DATE: November 5, 2018 NOVEMBER 5, 2018ORDER Entitlement to service connection for a psychiatric disability, claimed as PTSD, is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to an initial rating in excess of 30 percent for ischemic heart disease is remanded. FINDINGS OF FACT 1. The Veteran had active duty service in Vietnam during the Vietnam War. 2. The Veteran has a current diagnosis of PTSD based on in-service stressors. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active duty service from August 1969 to March 1971, to include service in Vietnam. Service Connection 1. Entitlement to service connection for a psychiatric disability, claimed as PTSD The Veteran asserts he has a current psychiatric disability, claimed as PTSD, resulting from his exposure to stressor events during service in Vietnam. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of a veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f). As with any claim, when there is an approximate balance of positive and negative evidence regarding any matter material to the claim, the claimant shall be given the benefit of the doubt. 38 U.S.C. § 5107. Participation in combat, a determination that is to be made on a case-by-case basis, requires that a veteran personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. See VAOPGCPREC 12-99; Moran v. Principi, 17 Vet. App. 149 (2003); see also Sizemore v. Principi, 18 Vet. App. 264, 273-74 (2004). If a stressor claimed by a veteran is related to a veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that a veteran’s symptoms are related to the claimed stressor, provided that the claimed stressor is consistent with the places, types, and circumstances of a veteran’s service, then the requirement for corroborating the stressor is eliminated. “Fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3) (as amended by 75 Fed. Reg. 39843 (effective July 12, 2010)). After a review of all the evidence, the Board finds that the Veteran’s accounts of coming under enemy fire and other traumatic stressors during service in Vietnam to be credible and consistent with the circumstances of his service. The service personnel records have been obtained and reviewed. These records confirm the Veteran had service in Vietnam, and the claimed in-service stressors are consistent with the places, types, and circumstances of service. The Veteran’s military occupational specialty was heavy truck driver, and he reported coming under fire while driving in convoys on a regular basis during his service in Vietnam. It was during such duty that he reported coming under hostile fire on occasion, and fearing for his life. The Veteran’s claimed in-service stressors are related to the threatened death or injury of himself and others from hostile military activity and his response to these events involved a psychological state of fear and helplessness. The evidence is at least in equipoise on the questions of whether the Veteran has PTSD that is related to an in-service stressful event or events. On VA examination in September 2013, a psychologist determined a current diagnosis of PTSD was not warranted. In support of his claim, however, the Veteran submitted a June 2014 statement from M.C., M.D., the Veteran’s private physician for many years. In his statement, Dr. C. confirmed a current diagnosis of PTSD based on the Veteran’s in-service stressors. The private physician who diagnosed the Veteran with PTSD in 2014 is noted to have treated the Veteran on many occasions prior to that diagnosis, and continued to conclude that a current diagnosis of PTSD was warranted. Thus, while the Board is cognizant of the September 2013 VA examination report and its conclusion, it does not find this evidence to be more probative than the remainder of the record. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for PTSD are met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. The Veteran seeks service connection for hypertension. He asserts this disability results from his stressful experiences in service. In the alternative, he asserts his hypertension is due to or aggravated by a service-connected disability. He has been granted service connection for diabetes mellitus, ischemic heart disease, bilateral tinnitus, and bilateral hearing loss. In an October 2013 statement, a VA physician opined that the Veteran’s hypertension was first diagnosed in 2003, whereas his diabetes was not diagnosed until 2004. Thus, the Veteran’s diabetes could not have caused his hypertension. The examiner did not, however, indicate whether the Veteran’s diabetes could have aggravated his hypertension. Thus, a medical opinion addressing this contention is necessary. Additionally, subsequent to the October 2013 opinion statement, the Veteran was granted service connection for ischemic heart disease, which he contends has aggravated his hypertension. A medical opinion is necessary to determine if an etiological nexus exists between these disabilities. 2. Entitlement to service connection for a low back disability is remanded. The Veteran seeks service connection for a low back disability. He has reported private medical treatment from Dr. M. Casagrande at least as recently as 2016. At the time this claim was initiated, the RO requested and obtained records of this treatment in July 2013, over five years ago. As the Veteran has notified VA of more recent treatment, a request for additional current medical records is necessary. Likewise, the RO should obtain any more recent VA treatment records. The most recent such records date to April 2016, over two years ago. 3. Entitlement to an initial rating in excess of 30 percent for ischemic heart disease is remanded. The Veteran seeks a disability rating in excess of 30 percent for his ischemic heart disease. Service connection was granted for this disability based on an October 2013 medical opinion which itself relied only on review of the medical records to determine a current level of disability. The Veteran was not afforded, and has not been afforded since that time, a current VA examination to determine the degree of impairment resulting from his service-connected ischemic heart disease. Where the record does not adequately reveal the current state of the claimant’s disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See 38 U.S.C. § 5103A(d); Chotta v. Peake, 22 Vet. App. 80, 84 (2008). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. M. Casagrande. Make two requests for the authorized records from this physician, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from April 2016 to the present. 3. Provide the Veteran’s claims file to an expert in cardiovascular disabilities to determine the nature and etiology of the Veteran’s current hypertension. The Veteran need not be scheduled for an in-person examination unless such an examination is deemed necessary by the examiner. Upon review of the file, the examiner is asked to specifically address whether it is as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is due to or results from his service-connected diabetes mellitus and/or ischemic heart disease. The examiner is also asked to state whether it is as likely as not that the service-connected diabetes mellitus and/or ischemic heart disease aggravates the Veteran’s hypertension. (For VA purposes, aggravation is defined as a permanent increase in disability beyond the natural progress of the disability.) The examiner is asked to provide a rationale for his/her opinion. (Continued on the next page)   4. Schedule the Veteran for a VA cardiovascular examination to assess the nature and severity of his coronary artery disease. The Veteran must be scheduled for a METs test, unless such testing is not medically advisable. The clinician should also provide specific examples of the Veteran’s activity level for the estimated METs, and provide a rationale for his estimated METs level. Any other impairment resulting from the Veteran’s ischemic heart disease must be noted for the record. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Thomas D. Jones, Counsel