Citation Nr: 18148128 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-41 159 DATE: November 6, 2018 REMANDED The issue of entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and major depressive disorder, is remanded. The issue of entitlement to service connection for dental trauma residuals to include “broken back teeth” and mouth injury residuals is remanded. REASONS FOR REMAND The Veteran had active service from March 1971 to January 1972. 1. The issue of service connection for a psychiatric disorder to include PTSD and major depressive disorder is remanded. The Veteran asserts that service connection for PTSD is warranted as the psychiatric disability originated during active service secondary to stressful in service experiences including being assaulted by fellow soldiers on multiple occasions. A May 2013 Department of Veterans Affairs (VA) psychiatric evaluation indicates that the Veteran reported that he “had endured many beatings during the service from fellow soldiers.” The Veteran was diagnosed with PTSD and major depressive disorder. An April 2016 VA mental health clinic treatment record states that the Veteran “has perhaps had PTSD at least from childhood experiences and as the result of an assault he suffered in the military by fellow soldiers.” The Veteran has not been provided a VA psychiatric examination to determine the nature of any psychiatric disabilities and their relationship, if any, to active service. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Clinical documentation dated after July 2018 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. The issue of service connection for dental trauma residuals to include “broken back teeth” and mouth injury residuals is remanded. The Veteran contends that service connection for dental trauma residuals is warranted as the claimed mouth or oral cavity injury was sustained when he was struck in the mouth while leading a basic combat training class at Fort Dix, New Jersey in 1971. The service medical and dental records of record do not refer to any dental, mouth, or oral cavity trauma. The Veteran reports that he has applied for Social Security Administration (SSA) benefits. Documentation of the Veteran’s SSA award of disability benefits, if any, and the evidence considered by the SSA in granting or denying the Veteran’s claim is not of record. VA’s duty to assist the Veteran includes an obligation to obtain the records from the SSA. Masors v. Derwinski, 2 Vet. App. 181 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for any psychiatric, dental trauma, or mouth injury disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records dated after July 2018. 3. Contact the SSA and request documentation of the Veteran’s award of benefits or the denial thereof and copies of all records developed in association with the decision. Document all requests for information as well as all responses in the claims record. 4. Schedule the Veteran for a VA psychiatric examination. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all psychiatric disabilities found. If PTSD is diagnosed, the examiner must identify the specific stressors upon which the diagnosis is based. The examiner should specifically state whether or not each criterion for a diagnosis of PTSD is met. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that each identified psychiatric disability had its onset during active service or is related to any incident of service, including claimed in service assaults by fellow servicemen. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel