Citation Nr: 18149500 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 16-24 743A DATE: November 9, 2018 ORDER New and material evidence having been submitted, reopening of the claim of entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to service connection for a psychiatric disability, to include PTSD, is remanded. FINDINGS OF FACT 1. In an unappealed April 2012 rating decision, the Veteran was denied entitlement to service connection for PTSD. 2. The evidence received since the April 2012 rating decision is not cumulative or redundant of the evidence of record at the time of the prior denial and relates to an unestablished fact necessary to establish the claim of entitlement to service connection for a psychiatric disability. CONCLUSION OF LAW New and material evidence has been received and the claim of entitlement to service connection for a psychiatric disability is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from May 1987 to February 1994. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In light of other psychiatric diagnoses of record, the Board has recharacterized the issue as entitlement to service connection for a psychiatric disability, to include PTSD. Clemons v. Shinseki, 23 Vet. App. 1, 4-6, 8 (2009). Claim to Reopen In an April 2012 rating decision, the RO denied entitlement to service connection for PTSD. The RO found that there was no current disability or a verifiable stressor. The Veteran did not appeal that decision. The evidence that has been received since the April 2012 rating decision includes an August 2014 VA psychiatric examination diagnosing adjustment disorder with mixed reaction, the Veteran’s lay assertion that she was beaten by several female soldiers during service, and VA treatment records noting additional diagnoses of a psychiatric disability, to include depression and anxiety disorder. The Board finds that the additional evidence is new and material as it has not been previously considered by VA and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a psychiatric disability. Therefore, reopening of the claim is warranted. REASONS FOR REMAND The Board finds that additional development is required before the remaining claim on appeal is decided. The Veteran has contended that she has a psychiatric disability that is related to service. Specifically, she has asserted that she was sexually assaulted in April and August 1990 while stationed at Fort Rucker, Alabama. She stated that she was assigned to 46th Engineers Bn (HHC) from September 1987 to August 1991. She alleged that the first sexual assault was committed by a sergeant temporarily assigned to her unit. She alleged that the second sexual assault was committed by a soldier and friend (CPL D. B.) permanently assigned to her unit. Additionally, the Veteran reported that she was beaten by several female soldiers. Service treatment records, to include the Veteran’s March 1987 enlistment examination, are silent for any symptoms related to, treatment for, or diagnosis of a psychiatric disability. In January 1993, the Veteran was physically assaulted. However, there is no service record evidence of any sexual assault incidents occurring in 1990. A review of post-service VA treatment records revealed that the Veteran was diagnosed with depression and anxiety disorder, and had additional manifestations of a psychiatric disability, to include PTSD. In August 2014, the Veteran was afforded a VA examination. In addition to the sexual assaults detailed above, the Veteran reported that, as the only female in her platoon, she had a hard time dealing with the men, who would call her names and engage her in physical fights. The examiner determined that the most descriptive diagnosis that could be given was adjustment disorder with mixed reaction, considering the Veteran’s reported history of abuse, interpersonal conflict, and presentation at the VA examination. The examiner opined that the Veteran’s psychiatric disability was less likely than not incurred in or caused by the Veteran’s service. In support of that opinion, the examiner stated that there was no record of mental health treatment and there were no allegations shown or medical treatment for such during service. The examiner added that the most consistent finding was response bias/exaggeration. The examiner stated that the Veteran’s psychiatric disability most likely preexisted her military service given her report of childhood molestation. However, the examiner noted that the Veteran’s VA treatment records were unavailable for review, to include 2009 VA Morehead City Clinic mental health treatment notes. The Board finds the August 2014 VA examination inadequate as there is no evidence that the examiner considered the physical assault that occurred in January 1993 and reviewed the Veteran’s mental health treatment records. Further, the Board finds the August 2014 VA medical opinion is not sufficient to prove that a psychiatric disability clearly and unmistakably preexisted service. Moreover, in light of the other psychiatric diagnoses of record, the Board finds that the Veteran should be provided an additional VA examination to determine the nature and etiology of any currently present psychiatric disability. In addition, current treatment records should be identified and obtained before a decision is made with regard to the remaining issues on appeal. The matter is REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, schedule the Veteran for a VA examination by a psychiatrist or psychologist with sufficient expertise to determine the nature and etiology of any currently present psychiatric disability, to include PTSD. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should first identify all psychiatric disabilities present during the pendency of the claim, or proximate thereto. Then, for each psychiatric disability identified, the examiner should provide an opinion as to whether such disability clearly and unmistakably existed prior to her active service, and if so, whether it was clearly and unmistakably NOT aggravated by service. For any identified psychiatric disability that did NOT clearly and unmistakably exist prior to the Veteran’s active service, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that such disability had its onset during active service, or is otherwise etiologically related to the Veteran’s active service, including as a result of her reported in-service sexual assaults and the physical assault that occurred in January 1993 and/or her report of being physically beaten by several female soldiers. The rationale for all opinions expressed must be provided. 3. Confirm that the VA examination report and all medical opinions provided comport with this remand and undertake any other development determined to be warranted. 4. Then, readjudicate the remaining claim on appeal. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Ware, Associate Counsel