Citation Nr: 18147949 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 17-44 287 DATE: November 6, 2018 REMANDED Service connection for an acquired psychiatric disability including posttraumatic stress disorder (PTSD), to include as secondary to service-connected headaches, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1962 to December 1965 in the United States Air Force. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Further development of the claim is required prior to appellate adjudication. In July 2018, the Veteran stated he received 2018 treatment at the New Hanover Regional Medical Center. The claims file, however, contain a single page of records from this facility, dated from 2016. The records must be requested. In addition, the Veteran attributes PTSD to a July 1965 in-service motor vehicle accident (MVA) in which he struck an oncoming car and caused the death of the passenger of that vehicle. The MVA is documented in the service treatment records (STRs), and the Veteran is currently service-connected for residuals of this accident, including posttraumatic headaches and a lumbar spine disability. However, whether the MVA resulted in a fatality has not been corroborated. An attempt to corroborate this aspect of the Veteran’s stressor should be made. Further medical opinion is also needed to resolve the claim. In his notice of disagreement, the Veteran reported that his psychiatric disability is secondary to his service-connected headaches. An opinion on the matter of secondary service connection has not yet been requested. Also, the record contains a May 2016 opinion of Dr. J. linking current PTSD to the MVA, without rationale. It also contains a July 2016 Disability Benefits Questionnaire in which the examiner found no current PTSD diagnosis despite the prior diagnosis of record. The July 2016 examiner also appeared unaware of the severity of the MVA, and noted there had been no traumatic brain injury despite STRs documenting a concussion. These opinions should be reconciled. The matter is REMANDED for the following action: 1. Contact the Veteran and ask him to complete a VA Form 21-4142 for New Hanover Regional Medical Center. Upon receipt of his completed form, make two requests for the authorized records from this facility, unless it is clear after the first request that a second request would be futile. 2. Contact the Veteran and ask him to provide any further identifying information regarding the fatality involved in the July 1965 motor vehicle accident. Thereafter, take appropriate actions to verify this aspect of the stressor. 3. Afford the Veteran a VA examination to obtain evidence addressing the etiology of his acquired psychiatric disability, to include PTSD. The examiner must consider the following evidence: May 2016 opinion of Dr. J.; July 2016 Disability Benefits Questionnaire; service treatment records corroborating a July 1965 motor vehicle accident in which the Veteran sustained a concussion. A rationale must be provided for all conclusions reached. (A.) All current disabilities must be identified. If there is disagreement with any prior psychiatric diagnosis, including the May 2016 PTSD diagnosis, the examiner must explain why. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. (B.) The examiner must further opine on whether it is at least as likely as not that any other current psychiatric disability (i.) began during active service or is related to an in-service injury, event, or disease, including the 1965 motor vehicle accident, or (ii.) was caused OR aggravated (chronically worsened) by the service-connected headaches. M. Tenner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith, Counsel