Citation Nr: 18149229 Decision Date: 11/09/18 Archive Date: 11/08/18 DOCKET NO. 16-36 546 DATE: November 9, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for residuals of cold injury to the left lower extremity is remanded. Entitlement to service connection for residuals of cold injury to the left upper extremity is remanded. Entitlement to service connection for residuals of cold injury to the right lower extremity is remanded. Entitlement to service connection for residuals of cold injury to the right upper extremity is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1952 to March 1954. On the August 2016 substantive appeal, the Veteran requested a Board videoconference hearing. On September 2018 written correspondence, the Veteran indicated that he was withdrawing his prior Board hearing request. The Board finds that the Veteran’s hearing request is withdrawn. 1. Entitlement to service connection for a low back disorder is remanded. 2. Entitlement to service connection for residuals of cold injury to the left lower extremity is remanded. 3. Entitlement to service connection for residuals of cold injury to the left upper extremity is remanded. 4. Entitlement to service connection for residuals of cold injury to the right lower extremity is remanded. 5. Entitlement to service connection for residuals of cold injury to the right upper extremity is remanded. Remand is required to obtain military hospital treatment records. It is necessary to ensure that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim, including making reasonable efforts to obtain relevant military medical records. 38 C.F.R. § 3.159(c)(1). The Veteran’s service treatment records and military personnel records were destroyed in an archive fire. In the September 2014 request for information to reconstruct medical data, the Veteran indicated that he was treated in Germany and Fort Ord, California. The Regional Office (RO) requested records related to Germany, but a December 2014 VA memorandum stated that no search was made because of the need for specific unit information. However, no such information was provided to enable the search. The December 2014 VA memorandum did not indicate that any military hospital records were searched and made no mention of attempting to search for records from Fort Ord. These records are of interest as they could include information regarding any in-service treatment and information related to the evaluation of the Veteran’s claimed low back and bilateral upper and lower extremity disorders. 6. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. Remand is required to obtain private treatment records. On the Veteran’s separation examination, he indicated that he was treated at Kern General Hospital for a mental disorder. These records are of interest as they could include information regarding information related to the Veteran’s asserted acquired psychiatric disorder. Also, remand is required to obtain a VA examination. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims indicated that there was a four-part test to determine whether an examination was necessary under 38 C.F.R. § 3.159(c)(4). Id. at 81. Under this test, VA will provide a medical examination or obtain a medical opinion where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence to make a decision on the claim. Id.; see also 38 C.F.R. § 3.159(c)(4). Here, on the Veteran’s separation examination, he indicated that he was previously hospitalized for a mental disorder at the local hospital in California. Further, the Veteran has asserted in his November 2013 claim for a mental disorder that he experienced nightmares, insomnia, and flashbacks. He stated that his mental disorder was caused by being fired upon in Germany. Therefore, the criteria for McLendon have been met. And as a result, the Board cannot make a fully informed decision on the issue to entitlement to service connection for an acquired psychiatric disorder because no VA examiner has opined whether the Veteran’s acquired psychiatric disorder was caused by service. The matters are REMANDED for the following action: 1. Obtain treatment records from the military hospital in Germany from March 1952 to March 1954. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Obtain treatment records from the military hospital at Fort Ord, California from March 1952 to March 1954. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 3. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination any relevant medical records. Specifically, look to obtain records from Kern General Hospital in Kern County, California from March 1952 to March 1954. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including treatment in Germany, at Fort Ord, and at the Kern General Hospital during service. The examiner must discuss the Veteran’s lay statements and contentions regarding the origin of his psychiatric disorder. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thompson, Associate Counsel