Citation Nr: 18148579 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 16-41 024 DATE: November 8, 2018 REMANDED Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for hypertensive vascular disease (claimed as hypertension) is remanded. REASONS FOR REMAND The Veteran served on active duty with the Navy from September 1976 to November 1980. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2014 and June 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes the RO first denied the Veteran’s service connection claim for hypertension in an August 2006 rating decision. He did not appeal this determination, and no new material evidence was submitted within a year following notification of the August 2006 denial. As a result, the August 2006 rating decision became final. 38 C.F.R. § 20.1103. However, in October 2017, the RO received service department records, which were deemed missing by the RO and were not previously associated with the claims file. These service department records existed prior to the August 2006 decision and are relevant to the claim at hand. Therefore, reconsideration of this claim is appropriate. 38 C.F.R. § 3.156 (c). Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c) (4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Entitlement to service connection for PTSD The Veteran contends that he has PTSD due to his service in the Navy. In a December 2016 Statement in Support of Claim for PTSD, the Veteran stated that he witnessed a semi-truck’s trailer roll up on a fellow airman crushing him and he experienced direct racism when he was assigned to the avionic shop, explaining that he was to lead the 2nd shift, but was replaced by the maintenance chief. The Board finds that the Veteran has not yet been afforded a VA examination for the purpose of determining whether his current PTSD can be related to his military service and a VA examination is necessary. The evidence shows that the Veteran has a current diagnosis of PTSD. He was first diagnosed with PTSD, meeting the DSM V criteria, in January 2015 by a psychologist, Dr. R.B. Subsequently, the Veteran sought treatment for PTSD through the VA. The first notation for treatment was from November 2015, where the Veteran participated in a phone consultation for problems with sleeping due to recalling incidents in the military and anger issues. In January 2016, the Veteran completed a behavioral health intake and was diagnosed with PTSD and other specified depressive disorder under DSM-V by Dr. J.I. He was prescribed sertraline and trazadone to treat his symptoms. In February 2016, the Veteran was diagnosed with anxiety disorder, unspecified by Dr. E.V., and was prescribed sertraline. The Veteran again sought treatment in October 2016 where his diagnosis of anxiety disorder, unspecified was continued. The Veteran’s statements regarding in-service stressors and his current PTSD diagnosis are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. Especially so given that one of the reasons for the previous denial was a lack of in-service diagnosis of a mental health disorder and newly obtained service treatment records (STR) have been added to the record. McClendon, 20 Vet. App. at 81. On remand, an opinion should be obtained as to whether the Veteran’s current PTSD is related to his military service. 2. Entitlement to service connection for hypertensive vascular disease (claimed as hypertension) The Veteran contends that he has been receiving treatment for hypertension for about 18 years. He further contends that his medical record shows that his blood pressure has always been high, but not high enough for medication while he was in the service. In his VA Form 9 dated August 2016, the Veteran added that he was diagnosed with hypertension in July 1977 and treated with Lisinopril and continued with medication and monitoring during his time in service. The Board finds that, while the Veteran was afforded a VA examination in June 2016 regarding his claim for service connection for hypertension, an addendum to the previous exam and/or an additional VA examination is necessary. On June 2016, the Veteran was afforded a VA examination for hypertension. The examiner reviewed the VA e-folder and CPRS records. The examiner concluded that a records review was sufficient and an examination was not necessary to render an opinion. The examiner opined that the Veteran’s hypertension was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided for this opinion was that without the availability of the Veteran’s STRs and/or post-service treatment records, it would be mere speculation to state whether it is at least as likely as not the Veteran’s hypertension had its onset during active service. The Veteran’s STRs, which were previously presumed missing, are now associated with the Veteran’s claims folder. Therefore, on remand, an opinion that accounts for a review of the STRs should be obtained. Due to the amount of time which will pass on remand, updated treatment records should be obtained and associated with the record. These matters are REMANDED for the following actions: 1. Contact the Veteran to determine if there are any relevant, outstanding private treatment records. If so, undertake all development necessary to obtain these records from each treatment provider and/or facility identified by him. 2. Obtain updated relevant VA treatment records and associate them with the claims file. 3. After the foregoing development has been completed, schedule the Veteran for an examination, by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted. All indicated tests and studies (to include psychological testing, if necessary) should be accomplished. After reviewing the claims file, the examiner should opine whether the Veteran has met the diagnostic criteria for PTSD using the DSM-V criteria at any time during the pendency of this appeal even if not found on the current examination. The examiner must provide an opinion as to whether it is as likely as not that the Veteran has PTSD which was etiologically linked to his active duty service. The examiner should address the favorable opinions provided in the Veteran’s VA treatment records in January and February 2016 and discuss whether the analysis of the Veteran’s PTSD under the DSM-V criteria meets the obligations of 38 C.F.R. § 4.125. The examiner should also address the results of the January 2015 evaluation administered by Dr. R.B. The VA examiner must provide a clear explanation for all opinions, to include any comment on any credibility issues raised by the record from a medical perspective. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer. 4. Schedule the Veteran for an examination or addendum opinion with an appropriate medical professional to determine the current nature and etiology of his claimed hypertension. After reviewing the claims file and STRs, the examiner is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hypertension, is related to active service or any incident of service, including the Veteran’s claim that he had high blood pressure in service. A rationale also should be provided for any opinions expressed. If any requested opinion cannot be provided without resorting to mere speculation, then the examiner should explain why. 5. Readjudicate the appeal. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Hartford, Associate Counsel