Citation Nr: 18153017 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 15-14 494A DATE: November 27, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1967 to October 1969. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision by a Department of Veterans Affairs Regional Office (RO). In May 2018, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. On August 16, 2018, the Federal Circuit ordered the appeal of Procopio v. Wilkie, No. 17-1821 (U.S. Fed. Cir.). The order stated that the questions before the Federal Circuit include the following: “Does the phrase ‘served in the Republic of Vietnam’ in 38 U.S.C. § 1116 unambiguously include service in offshore waters within the legally recognized territorial limits of the Republic of Vietnam, regardless of whether such service included presence on or within the landmass of the Republic of Vietnam?” As of the date of this decision, Procopio is pending. In addition to the issues on the title page, the Veteran has claimed entitlement to service connection for a heart disorder. At his May 2018 Board hearing the Veteran’s representative claimed that the Veteran’s heart disorder may be related to his Agent Orange exposure when he was in offshore waters near Vietnam. Therefore, the issue of service connection for a heart disorder may be affected by the resolution of Procopio, and the Board will “stay” or postpone action on this matter. 1. Entitlement to service connection for an acquired psychiatric disorder, to include personality disorder is remanded. 2. Entitlement to service connection for a left shoulder disorder is remanded. With regard to the Veteran’s claims for an acquired psychiatric disorder and a left shoulder disorder, the Board notes that he has not been provided with VA examinations. Regarding his left shoulder disability, the Board notes the Veteran has reported hurting his left shoulder while loading ammunition on a ship in service. See May 2018 Board Hearing Transcript p.4. The Veteran’s service treatment records reflect reports of left shoulder pain in January 1969. At his May 2018 Board hearing, the Veteran reported continued pain in his left shoulder following service. Regarding his claim for an acquired psychiatric disorder, the Veteran has reported that he has had symptoms of a mental health disorder since his discharge from service, specifically issues with anger and isolation from others. See May 2018 Board hearing transcript pp. 25-27. The medical evidence of record shows that in service, in July 1969, a notation was made of suspected personality disorder. Furthermore, the Veteran was reported to have in July 1969 an emotionally unstable personality. The Veteran’s October 1969 separation examination was normal; however, at his May 2018 Board hearing the Veteran reported that he had ongoing psychiatric issues following his discharge from service, and that he tried to seek treatment from VA facilities but was turned away because he was not already service connected for the condition. VA must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2018). The third prong, which requires evidence that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. The Board recognizes the recent ruling by the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) in Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018), that found “pain alone can serve as a functional impairment and therefore, qualify as a disability.” The Board notes that the evidence of record shows that the Veteran has had consistent complaints of severe left shoulder pain, and has reported having psychiatric problems which affect his daily life since his discharge from service. There is no medical opinion of record as to whether the Veteran has either a left shoulder disability or an acquired psychiatric disorder related to service. Thus, the Board finds that examinations are required for both of the claimed disabilities in order to obtain opinions addressing the nature and etiology of any diagnosed left shoulder or acquired psychiatric disabilities. Id., See McLendon, supra. Moreover, with regard to both his left shoulder and psychiatric disability, the Veteran has claimed that he has sought private treatment from Dr. S.G., and these private records are not associated with the claims folder. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all private treatment records from the Veteran not already associated with the file. Specifically, attempts should be made to obtain records from Dr. S. Grooms at Methodist Healthcare, Dr. Woodland at the Southern Clinic, and from Baptist East. If any treatment records are unavailable, issue a formal finding of unavailability and notify the Veteran so that he can submit any medical records in his possession. 2. Obtain the Veteran’s complete service personnel records and associate them with the claims file. 3. Only after completion of the above specified development, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any currently diagnosed psychiatric condition. The examiner should provide the following opinions: (a) Does the Veteran have any currently diagnosed psychiatric disorder? (b) Is at least as likely as not (50 percent or greater probability) that any diagnosed acquired psychiatric condition is etiologically related to his period of service? The examiner should specifically address the July 1969 treatment record of suspected personality disorder while in service and the July 1969 notation of an emotionally unstable personality and the Veteran’s continued complaints of psychiatric symptoms since service. A complete rationale for all opinions should be provided. 4. Only after completion of the above specified development in 1-3, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any currently diagnosed left shoulder condition. The examiner should provide the following opinions: (a) Does the Veteran have any currently diagnosed left shoulder disorder? (b) Is at least as likely as not (50 percent or greater probability) that any diagnosed left shoulder condition is etiologically related to his period of service? The examiner should specifically address the in-service reports of left shoulder pain in January 1969 and the Veteran’s reports of continued and significant left shoulder pain since service. A complete rationale for all opinions should be provided. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Kamal, Associate Counsel