Citation Nr: 18150337 Decision Date: 11/15/18 Archive Date: 11/14/18 DOCKET NO. 12-20 123 DATE: November 15, 2018 REMANDED The claim of entitlement to service connection for a seizure disorder claimed as secondary to head trauma is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from May 1979 to January 1981. The Veteran’s service was under honorable conditions. In an August 2015 decision, this matter was remanded for additional development to include obtaining a VA opinion. Regrettably, an additional remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (West 2014); 38 C.F.R. § 3.159 (2018). 1. Entitlement to service connection for a seizure disorder claimed as secondary to head trauma is remanded. The Veteran contends that he is entitled to service connection for a seizure disorder as secondary to head trauma sustained in service. Review of service treatment records show that the Veteran was physically assaulted in November 1980. An emergency treatment record indicated that he was beaten and kicked in the attack. A possible loss of consciousness was suggested. During the physical evaluation, the Veteran complained of injuries to the head and face, left forearm, chest, and left knee. Multiple abrasions and contusions were visible about the face and skull. X-ray films of the face were negative for any evidence of fractures. The Veteran was admitted to the hospital and evaluated overnight due to his head trauma. Thereafter, he was placed on profile for 7 days. In the same month, the Veteran was treated for complaints of dizziness, blacking out, and pain behind the left eye. He stated that he was struck in head, near the temple. Due to ongoing complaints of headaches and left eye pain, the Veteran an X-ray of the skull was recommended. Diagnostic imaging revealed a normal cranial vault; with no abnormal calcifications. Complaints of dizzy spells and headaches were previously noted in July 1979. The treatment record noted heat exhaustion the possible cause of the reported symptoms. Post-service treatment records show that the Veteran was evaluated for worsening memory loss associated with prior head trauma. In April 2002, a computerized tomography (CT) scan of the head revealed mild cerebral atrophy. The Veteran underwent a magnetic resonance imaging (MRI) evaluation in November 2003. Diagnostic findings showed partial complex seizures. In March 2016, the Veteran was afforded a VA examination. Although the examiner acknowledged his current diagnosis of psychomotor epilepsy, it was nevertheless concluded that the condition was not causally related to active service. In support of the stated conclusion, the examiner reasoned that if the Veteran suffered from post-traumatic epilepsy as due to his in-service treatment for head injuries, the condition would likely have developed within the first two years after injury. It was further suggested that the Veteran had a history of severe alcohol abuse for approximately 15 years. His current memory deficit is more likely due to alcohol abuse rather than two concussions sustained decades earlier. In a lay statement, dated April 2016, the Veteran disputed the VA examiner’s findings. Specifically, he contends that the examiner’s opinion that his epilepsy is causally related to 15 years of heavy drinking is inaccurate. The Veteran reports that he stopped drinking in 1983, prior to the birth of his first child. Lay statements from his wife and son confirm remission of alcohol use since the earlier 1980’s. Further, he contends that his symptoms including frequent headaches, body tremors, and memory loss date back to active service. According to the Veteran’s wife, she became aware of the Veteran’s symptoms in 1981. She stated that soon after separation, the Veteran sought treatment at VA facilities but he was denied services. Later, he reportedly sought treatment from a private physician, but the recommended testing was too expensive. There is no evidence that the records related to the asserted treatment were ever requested. In addition, the Veteran reported that service treatment records from his period of service in Korea have not been associated with the claims file. According to the Veteran, he suffered a stroke while serving in Korea and was flown to a military hospital where he was observed for 3 days. Upon release, he was placed on profile and restricted to light due for 7 days. If available, these records must be obtained. As to the March 2016 VA examination, the Board finds the examiner’s opinion inadequate. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See 38 U.S.C. § 5103(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On examination, the examiner confirmed the Veteran’s current diagnosis of a seizure condition, but suggested that his symptoms were causally related to years of alcohol abuse. There is no evidence that the Veteran was treated for an alcohol dependence and he in fact, denied any use of alcohol since the early 1980’s. Further, the examiner’s opinion suggests that any causally related post-traumatic seizure disorder would likely have occurred within 2 years of the Veteran’s head injury. In multiple lay statements, both the Veteran and his wife, symptoms including severe headaches, body tremors and memory loss were reported in 1981. Separation from active duty occurred in January 1981. Accordingly, the Board finds that a new VA opinion is required. This matter is REMANDED for the following action: 1. Contact the Veteran to request identification of any additional VA and/or private providers of treatment received for his seizure disorder, to include treatment for symptoms such as headaches, body tremors, and memory loss, prior to April 2002. Specifically, the Veteran is requested to identify providers of treatment related to his in-service head injuries soon after separation in January 1981. For all providers identified, any appropriate authorizations should be obtained and requested and forwarded to the providers indicated. Documentation of all correspondence related to the requests for records and any responses received must be associated with the claims file. 2. Contact the appropriate records custodian to obtain the Veteran’s reported service treatment records for the period of service between July 24, 1979, and May 13, 1980 while serving in Korea. The Board notes that the Veteran has suggested receipt of treatment relevant to his pending treatment while stationed in Korea during the time frame indicated. Any response and/or records received must be associated with the claims file. 3. Only if additional records are located, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his seizure disorder. The entire claims file, to include any newly associated records and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability), that the Veteran’s seizure disorder was caused by or otherwise related to active service, to include as due to multiple head injuries sustained in-service. As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. Likewise, the lay statements of record should be considered and discussed, as well as the March 2016 VA examination. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 4. After completing the above, and any additional development deemed necessary, the Veteran’s claim should be re-adjudicated based on the entirety of the evidence. If the benefits sought on appeal remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel