Citation Nr: 18147007 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 16-28 286 DATE: November 5, 2018 REMANDED Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for an acquired psychiatric disability, to include major depression, manic depressive disorder, bipolar disorder, and posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active military service in the U.S. Army from June 1980 to March 1985. At the outset, the Board notes that these claims were originally denied in a September 2005 rating decision, which the Veteran did not appeal, and the decision became final. 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2005). The available evidence only included an entrance examination report. However, in connection with the current claims, the Veteran’s complete service treatment records were added to the claims folder requiring a readjudication of the claims. 38 C.F.R. § 3.156(c); Blubaugh v. McDonald, 773 F.3d 1310, 1313 (Fed. Cir. 2014). Although the Board regrets the additional delay, remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that she is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). 1. Entitlement to service connection for bilateral pes planus is remanded. Upon entry into service the Veteran was noted to have bilateral pes planus. However, the Veteran contends that active military service and the required combat boots aggravated said condition, as she now experienced possible structural changes to her foot, including a visible knot at the top. Therefore, the Veteran should be offered an examination to determine the extent, if possible military service aggravated her pre-existing foot disabilities. 2. Entitlement to service connection for bilateral hearing loss is remanded. 3. Entitlement to service connection for tinnitus is remanded. The Veteran contends that while in the military she would frequent the rifle range and shoot guns without hearing protection. She currently alleges that she first noticed difficulty hearing in 1983 while in Germany, which had progressively worsened since service. The Board needs additional information prior to adjudicating these claims. As such, the Veteran should be afforded a VA examination in connection with these claims. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d)(1); 38 C.F.R. § 3.159(c)(4) (holding, in relevant part, that in order to trigger VA’s duty to provide an examination or obtain an opinion, there must be insufficient evidence to decide the case); see also 38 C.F.R. § 3.159(c)(4). 4. Entitlement to service connection for an acquired psychiatric disability, to include major depression, manic depressive disorder, and bipolar disorder and PTSD is remanded. Service treatment records from February and March 1983 reflect that the Veteran was treated for hyperventilation syndrome and anxiety as the records note that the Veteran was very anxious and upset because of her job, which is consistent with her hearing testimony being upset about wrongfully receiving a performance evaluation, and sexual and racial discrimination within her unit. The Veteran underwent VA examination in March 2016, but the examiner failed to discuss any of the Veteran’s other psychiatric diagnoses other than bipolar disorder. Moreover, the examiner failed to address whether the Veteran’s described racial and sexual discrimination during service had any bearing on her presently diagnosed psychiatric disabilities. Once VA undertakes a duty to provide a medical examination, due process requires an adequate medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Consequently, a remand is necessary for another examination. The examiner should provide adequate rationale for any opinion rendered. The matters are REMANDED for the following action: 1. Associate with the claims file any outstanding VA and private treatment records. Assist the Veteran in obtaining complete medical records from Dr. James Ballard of Behavioral and Social Systems, Inc., since 1996. 2. Afford the Veteran appropriate VA examinations to determine the nature and etiology of her claimed conditions bilateral pes planus. The examiner is requested to identify all current right and left foot disorders. With respect to pes planus, provide opinion whether it is at least as likely as not (50 percent or greater probability) that the pre-existing pes planus was aggravated beyond the normal progress of the disorder during active service, to include wearing combat boots for extended periods of time. The examiner is instructed that temporary or intermittent flare-ups of a pre-existing disease during service is insufficient to be considered aggravation, unless the underlying condition, as contrasted to symptoms, worsens. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). For any disorders other than pes planus, whether it is at least as likely as not (50 percent or greater probability) that any claimed condition had its onset or is etiologically related to the Veteran’s period of active service, to include wearing combat boots for extended periods of time. The examiner is requested to explain whether there is any medical reason to accept or reject the Veteran’s contentions that her foot structure changed as a result of wearing combat boots. 3. Schedule the Veteran for audiologic examination to determine the nature and etiology of her claimed hearing loss and tinnitus. If the Veteran meets the criteria for hearing loss disability, provide opinion as to whether it is at least as likely as not the Veteran’s hearing loss had its onset or is etiologically related to her period of active service including training at the rifle range without hearing protection. The examiner should also provide opinion as to whether it is at least as likely as not the Veteran’s tinnitus had its onset or is etiologically related to her period of active service to include training at the rifle range without hearing protection. 4. Schedule the Veteran for psychiatric examination. The examiner should specifically indicate whether the Veteran meets the diagnostic criteria for PTSD and whether such diagnosis is the result of an in-service personal assault, to include sexual harassment and racial discrimination. In this regard, the examiner should review the transcript of the Veteran’s May 2018 hearing and describe the markers in personnel records which may corroborate that personal assault occurred. The examiner should identify any diagnosis other than PTSD, to include the previously diagnosed major depression, manic depressive disorder, and bipolar disorder. The examiner is requested to discuss whether the previously diagnosed major depression, manic depressive disorder, and bipolar disorder was proper and currently asymptomatic, or a misdiagnosis. For each diagnosed acquired disorder which had been properly diagnosed, please provide opinion whether it is at least as likely as not that such disorder(s) had it onset in service or is attributable to an event in service, to include the Veteran’s reported sexual and racial discrimination. A rationale for any opinion offered should be provided (continued on next page) 5. Upon completion of the above, and any additional development deemed appropriate, the AOJ should readjudicate the remanded issue(s). If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response, the appeal must be returned to the Board for appellate review. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.L. Reid, Associate Counsel