Citation Nr: 18148181 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 18-01 124 DATE: November 7, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD), originally claimed as other specified trauma and stressor-related disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from October 1987 to July 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina (Agency of Original Jurisdiction (AOJ)). The Board notes that the Veteran filed a claim in August 2015 for entitlement to service connection for a hearing condition, PTSD, sleep apnea, and hypertension; however, it does not appear that this claim was ever adjudicated. In the interim, the Veteran’s claim for entitlement to service connection for hypertension was denied by a February 2016 Board decision, while his claim for entitlement to service connection for sleep apnea was granted in a September 2015 AOJ rating decision. As the Veteran’s claim for entitlement to service connection for PTSD is encompassed in the claim currently pending on appeal, the only claim left to adjudicate is the Veteran’s claim for entitlement to service connection for a hearing condition. The Board subsequently refers this claim back to the AOJ for adjudication. 1. Entitlement to service connection for an acquired psychiatric disorder to include PTSD is remanded. The Veteran contends that he has a stress condition related to his time in service. Specifically, he requests service connection based on the provisions of 38 C.F.R. §3.304(f)(3), which pertains to service connection for PTSD related to fear of hostile military or terrorist activity. He recounts how, during his deployment, he served on the USS Blueridge during Operation Desert Shield/Desert Storm and lived under life-threatening conditions with inherent dangers including land-to-sea missiles and air/sea attacks. In December 2016, the Veteran provided a treatment record from his private physician, Dr. H.J., who performed a psychiatric evaluation on the Veteran. Based on the Veteran’s symptoms, which included disturbing memories and thoughts, nightmares, and avoidance traits, Dr. H.J. diagnosed the Veteran as having other specified trauma and stressor-related disorder and unspecified depressive disorder. He opined that it was at least as likely as not that the Veteran’s other specified trauma and stressor-related disorder was incurred in or caused by his military service and results from a fear of hostile military or terrorist activities. However, a VA examination conducted in January 2017 failed to diagnose the Veteran with any psychiatric condition other than unspecified depressive disorder. Furthermore, the examiner, Dr. M.B.B., opined that his condition was less likely than not incurred in or caused by the claimed in-service event. She rationalized that the Veteran did not receive any mental health treatment during service, nor did he seek treatment until the mid-2000s. The psychologist went on to note that Dr. H.J. did not have access to the Veteran’s service treatment records (STRs) when making his assessment, whereas she had the opportunity to review them. The Board finds that the VA examination is flawed, as it does not take into consideration Dr. H.J.’s diagnosis and provide reasons or rationale for why the Veteran does or does not have that particular diagnosis. Therefore, the Board will remand to afford the Veteran an opportunity to present for a new examination and to obtain an opinion as to the etiology of any acquired psychiatric disorder. The matter is REMANDED for the following action: 1. The AOJ shall associate the Veteran’s most recent outstanding VA medical treatment records with his file, specifically those records from January 2017 to the present pertaining to any acquired psychiatric disorder and/or PTSD. 2. Ask the Veteran to complete a VA Form 21-4142 for any private treatment providers that have treated him for any acquired psychiatric disorder to include PTSD. Thereafter, obtain and associate with the claims folder any private treatment records identified. 3. Then, the Veteran should be afforded an appropriate VA examination in order to determine the current nature and etiology of any acquired psychiatric disorder to include PTSD. The claims file must be made available to and be reviewed by the examiner. The examiner should specifically indicate whether the Veteran has an acquired psychiatric disorder to include PTSD, and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such acquired psychiatric disorder occurred in or is otherwise etiologically related to the Veteran’s military service, to include his service on the USS Blueridge during Operation Desert Shield/Desert Storm. The examiner should specifically indicate whether the Veteran has the diagnoses previously suggested by Dr. H.J. and Dr. M.B.B., and explain why or why not. The examiner should consider the following: • VA treatment records associated with the file in November 2009, reflecting negative depression and PTSD screenings; • the Veteran’s STRs; • lay statements associated with the file in April 2011; • VA treatment records associated with the file in June 2015; • CAPRI treatment records associated with the file in July 2015, September 2015, April 2016, and January 2017; • Dr. H.J.’s medical opinion associated with the file in December 2016; • the Veteran’s Statement in Support of Claim for PTSD recording his stressors, associated with the file in December 2016; and • the January 2017 VA examination. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Thereafter, readjudicate the claim. If any benefit sought on appeal remains denied, furnish the Veteran and his representative, if any, a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Victoria A. Narducci, Associate Counsel