Citation Nr: 18147370 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 16-38 524 DATE: November 5, 2018 REMANDED The issue of entitlement to service connection for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2005 to January 2013. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran seeks entitlement to service connection for his right shoulder condition primarily on a secondary basis, asserting that his right shoulder disability was caused or aggravated by his service-connected left shoulder disability. While the Board regrets the additional delay, due to the VA’s failure to assist, the Veteran’s claim of entitlement to service connection for right shoulder sprain must be remanded. The VA has the duty to make reasonable efforts to assist a claimant in securing evidence necessary to substantiate their claim for VA benefits. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The RO did not meet its duty to assist when it did not refer the Veteran for a VA examination to address whether the Veteran’s right shoulder condition is at least as likely as not service connected on a direct, or secondary, basis prior to issuance of the July 2016 Statement of the Case. The VA must obtain an examination in service connection claims when there is an indication that the current disability may be associated with the Veteran’s service and there is a lack of sufficient evidence to decide the claim. See McClendon v. Nicholson, 20 Vet. App 79, 83 (2006). Service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The Veteran underwent a VA examination in June 2016. The VA examiner diagnosed the Veteran with a right shoulder strain, and suspected there was a rotator cuff condition. However, the VA examiner did not provide any opinion regarding the direct or secondary cause of the Veteran’s right shoulder condition. Therefore, the record is devoid of any medical analysis addressing whether in service events may have caused or contributed to his right shoulder sprain on a direct basis, or whether the right shoulder sprain is secondary to his service connected left shoulder disability. By his November 2014 Notice of Disagreement, the Veteran asserted that he believed his right shoulder condition deteriorated beyond normal progression due to the overuse required because of his service connected left shoulder disability. Essentially, he claimed that his right shoulder condition was secondary to his service connected left shoulder condition. The VA must obtain an examination in service connection claims when there is competent evidence of a current disability or persistent or recurrent symptoms of a disability, when there is an indication that the current disability may be associated with an in-service vent, or an already service-connected disability, and there is a lack of sufficient evidence to decide the claim. See McClendon v. Nicholson, 20 Vet. App 79 (2006). In this case, the RO did make the effort to schedule a VA examination, but the VA examination did not provide any opinion regarding causation. The case law is clear that once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, he must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Because the VA examiner did not address whether the Veteran’s right shoulder condition is at least as likely as not service connected on a direct, or secondary, basis the duty to assist was triggered. Accordingly, a VA examination addressing whether the Veteran’s right shoulder condition is at least as likely as not service connected on a direct basis, or on a secondary basis, is needed prior to adjudication of the claim for service connection for the Veteran’s right shoulder strain. The matter is REMANDED for the following action: 1. Obtain all of the Veteran’s VA medical records and associate them with the record. See 38 C.F.R. § 3.159(c). All actions to obtain the records should be documented. Any negative results should be noted in the record and communicated to the Veteran pursuant to 38 U.S.C. § 5103A(b) and 38 C.F.R. § 3.159(e)(1). 2. After the development directed in paragraph one has been completed to the extent possible, schedule the Veteran for an examination to determine the nature and etiology of the claimed right shoulder condition. The examiner should obtain a complete, pertinent history from the Veteran and review the claims file in conjunction with the examination, giving particular attention to his VA treatment records, lay assertions, and the pertinent medical evidence. The complete claims folder should be provided to the examiner, and the examiner should specifically state that the complete folder has been reviewed. In formulating the requested opinions, the examiner is asked to specifically consider and address the Veteran’s service treatment records and consider the evaluation from June 2016. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and chronic nature of his symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. Based on the examination and review of the record, the examiner is asked to provide an opinion whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the right shoulder condition was incurred in service, or is otherwise attributable to the Veteran’s service (caused by or made permanently worse as a result of his service connected left shoulder disability). Any evaluations, studies, or tests deemed necessary by the examiner should be accomplished and any such results must be included in the examination report. A complete rationale for any opinion expressed must be provided. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. After completing the requested actions, and any additional actions deemed warranted, the AOJ should readjudicate the claims on appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. S.C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Temple, Associate Counsel