Citation Nr: 18148872 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-38 991 DATE: November 8, 2018 ORDER An effective date prior to November 28, 2012, for the grant of service connection for posttraumatic stress disorder (PTSD). REMANDED Entitlement to service connection for a right ankle disability. Entitlement to service connection for residuals of hernia, status post-surgery. Entitlement to an initial rating in excess of 50 percent for PTSD. INTRODUCTION The Veteran served on active duty from October 2004 to March 2009. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. FINDING OF FACT The Veteran submitted a claim of entitlement to service connection for PTSD, which was date-stamped as received by VA on November 28, 2012. CONCLUSION OF LAW The criteria for an effective date prior to November 28, 2012, for the grant of service connection for PTSD have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDING AND CONCLSION The Veteran submitted a claim of entitlement to service connection for PTSD that was date-stamped as received on November 28, 2012. Service connection for PTSD was granted in an October 2013 rating decision, and an effective date of November 28, 2012, was assigned to the initial 50 percent rating. The Veteran perfected an appeal seeking an earlier effective date. Governing law provides that the effective date for a grant of service connection is the day after separation from service or day entitlement arose, if a claim is received within one year after separation from service, otherwise the date of receipt of claim, or the day entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). To date, the Veteran has not submitted or identified any evidence or argument as to the basis for his claim that he is entitled to an effective date prior to November 28, 2012, for the grant of service connection for PTSD. The Veteran has not asserted, and the evidence of record does not support finding that he submitted or VA received a formal or informal claim of entitlement to service connection for PTSD prior to November 28, 2012. As such, the Board finds that an effective date prior to November 28, 2012, for the award of service connection for PTSD is not warranted. 38 C.F.R. § 3.400. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim for an earlier effective date, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND Right Ankle and Residuals of Hernia Surgery The Veteran was not provided a VA examination pursuant to either of these claims. In order to satisfy VA’s duty to assist, the Board finds that a remand is required to provide the Veteran a VA examination. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). PTSD The most recent VA examination occurred in February 2015. This examination is too remote, and the evidence of record is otherwise insufficient, to adequately assess the current severity of the Veteran’s PTSD, especially because subsequent treatment records suggest possibly worsening since then. As such, a remand is warranted to provide the Veteran an additional VA examination. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that VA’s duty to assist includes providing a thorough and contemporaneous medical examination). The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims. Based on his response, attempt to procure copies of all records which have not previously been obtained from identified treatment sources. 2. Provide the Veteran with a VA examination regarding his claimed right ankle disability and any post-operative residuals of a hernia. Make the Veteran’s electronic claims file available to and ensure that it is reviewed by the examiner. All pertinent symptomatology and findings must be reported. Any indicated tests that are deemed necessary for an accurate assessment must be conducted. The examiner should then provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) a current right ankle disability and/or any post-operative residuals of a hernia was/were incurred in or due to his active duty. In so doing, the examiner must specifically consider and discuss the Veteran’s assertions regarding in-service events. Further, the examiner is advised that musculoskeletal pain resulting in functional impairment is considered a current disability. All rendered opinions must be accompanied by a thorough rationale. 3. Provide the Veteran a VA examination to determine the current degree of severity of his PTSD. Make all pertinent evidence of record available to the examiner and instruct the examiner to review that evidence. Ensure that the examiner provides all information required for rating purposes. (Continued on next page) 4. Re-adjudicate the claims. If the benefits sought remain denied, then issue a supplemental statement of the case to the Veteran. Provide him a reasonable opportunity to respond. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Sean G. Pflugner, Counsel