Citation Nr: 18152507 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 16-48 800 DATE: November 23, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) or anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served honorably from May 1985 to September 1992. This matter is on appeal from a December 2013 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). Entitlement to service connection for an acquired psychiatric disability, to include PTSD and anxiety disorder is remanded. The Board must provide a medical examination or obtain a medical opinion when necessary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). An examination is necessary when there is: (1) evidence of a current disability, or recurrent symptoms of a disability; (2) evidence establishing an in-service injury or disease occurred that would support incurrence or aggravation; (3) an indication that the current disability may be related to the in-service event; and (4) insufficient evidence to decide the case. Id.; 38 C.F.R. § 3.159(c)(4). Generally, for service connection to be awarded for PTSD, three elements must be present: (1) medical evidence establishing a current diagnosis of the disability in accordance with the DSM-IV or DSM-5, (2) credible supporting evidence that the claimed in-service stressor actually occurred, and (3) a causal nexus, established by medical evidence, linking the current symptomatology to the claimed in-service stressor. See Moreau v. Brown, 9 Vet. App. 389 (1996). 38 C.F.R. §§ 3.304(f), 4.125(a). Here, the Veteran seeks service connection for an acquired psychiatric disability, to include PTSD and anxiety disorder. The Veteran asserts that his acquired psychiatric disorder is the result of a traumatic flight from Miami to Panama on 11 August 1990. The supplemental materials submitted by the Veteran outlining the severity of the 1990 hurricane season show that no hurricane, nor any tropical storm, nor tropical depression, was in the vicinity of a flight path from Miami to Panama on that day. In order for this to qualify as a stressor to satisfy that element of a PTSD claim, this event would have to be corroborated by credible supporting evidence. Clinical records from a week after the flight state that the Veteran was suffering from hair loss and possible situational anxiety. He was referred to a mental health clinic, but no records from such clinic are in the record. The Veteran reports that after the flight incident that he became angry and combative with the other firefighters and people around him. Performance reviews from the time of the incident and afterward praise the Veteran for excellent conduct and commend him for his calm and maturity. The Veteran has submitted records showing treatment for PTSD and anxiety disorder with a private psychologist. These records show treatment for anxiety and contain a report from 2011 that anxiety symptoms began many years before that time. However, these records do not contain an opinion regarding the etiology of the Veteran’s PTSD or anxiety disorder, nor the likelihood that either was related to his service. The Board finds that the medical evidence of record is insufficient to make a decision on the claim. The record does not contain a statement by a credible clinician opining on whether a psychiatric disability, to include PTSD or anxiety disorder, either had its onset in active service or is otherwise related to active service or to a service-connected disability. Hence, the Veteran is entitled to an examination. The matter is REMANDED for the following action: 1. Obtain the Veteran’s outstanding VA treatment records and associate them with the Veteran’s claims file. 2. Contact the Veteran to notify him that in order to be successful in his claim of service connection for PTSD it must be found to be due to an in-service stressor that has been corroborated by credible independent supporting evidence, and that his claimed traumatic flight from Miami to Panama on 11 August 1990 has not been independently corroborated, and that records have shown that the severity of the 1990 hurricane season show that no hurricane, nor any tropical storm, nor tropical depression, was in the vicinity of a flight path from Miami to Panama on that day. The Veteran should be asked to provide any other evidence that he may have, or the location thereof, that would independently corroborate this claimed stressor or any other in-service stressor, and be given a reasonable period of time to respond. 3. Thereafter, the RO or VA’s Appeals Management Center (AMC) should make a determination as to whether there is an in-service stressor that has been corroborated by credible independent supporting evidence, and such determination should be made a part of the Veteran’s claims file. 4. Thereafter, schedule the appropriate VA examination to determine the existence, nature, and etiology of any current psychiatric disorder including the Veteran’s claimed PTSD and anxiety disorder. (a.) An opinion regarding PTSD should only be made with respect to any stressor(s) that has been corroborated by independent evidence, as identified by the RO prior to the scheduling of the examination. (b.) If the evidence does not corroborate an in-service stressor for PTSD, the examiner may still freely provide a nexus opinion regarding any other diagnosed disability, such as anxiety disorder. The examiner should opine as to: (c.) The existence of any current acquired psychiatric disorder, including PTSD or anxiety disorder. (d.) If PTSD is found, whether it is at least as likely as not (a 50 percent probability or more) due to a stressor event that occurred during the Veteran’s active service and that has been corroborated by independent evidence, as identified by the RO. (e.) If anxiety disorder is found, whether it at least as likely as not either had its onset in active service, or is otherwise related to the Veteran’s active service. (f.) If any other psychiatric disability is found, whether it is as likely as not cause by or aggravated by the Veteran’s active service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The Veteran’s claims file, to include a complete copy of this REMAND, must be available to the examiner designated to examine the Veteran, and the examination report should note review of the file. All opinions and conclusions expressed must be supported by a complete rationale in a report. 5. After ensuring that the requested actions are completed, the RO or VA’s Appeals Management Center (AMC) should re-adjudicate the claim on appeal. If the benefits sought are not fully granted, the RO or AMC must furnish a SSOC, before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran until he is notified by the RO or AMC; however, the Veteran is advised that failure to report for any scheduled examinations may result in the denial of his claims. 38 C.F.R. § 3.655 (2015). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S.W. Strike, Associate Counsel