Citation Nr: 18153359 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 15-18 921 DATE: November 27, 2018 REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for migraine headaches including as secondary to a neck disability is remanded. Entitlement to an initial evaluation in excess of 30 percent disabling for service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from June 1967 to June 1970. The Veteran testified at a November 2018 Board hearing held before the undersigned via videoconference. The transcript from the hearing has not yet been associated with the file, as the case is being remanded under the Board’s “One Touch” program. The hearing transcript will still be processed and associated with the claims file in the ordinary course of business. The issues on appeal have been expanded to include a claim of entitlement to a TDIU. The Veteran indicates that he is not currently employed due, at least in part, to his service-connected PTSD for which he seeks a higher rating. Entitlement to a TDIU is “part and parcel” of the determination of the appropriate rating for a disability. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009). 1. Entitlement to service connection for a neck disability is remanded. The Veteran seeks entitlement to service connection for a neck disability, but has not had the benefit of a VA examination and opinion to address the etiology of that neck condition. The evidence of record establishes that the Veteran has a current neck disability and a history of a fracture of the cervical spine. Moreover, he is a decorated combat veteran who received the Bronze Star for valor (“For heroism in ground combat against an armed hostile force” including “rush[ing] to the aid of his fallen comrade, under heavy enemy fire[,] stay[ing] with the injured men” and defending the position against many enemy who reached “within five meters of his position”) with both a 1st Oak Leaf Cluster valor (“For heroism in ground combat against a hostile force” including “personal bravery and devotion” demonstrated by “charg[ing] the enemy, providing a heavy volume of fire that completely routed the enemy force”)and a 2nd Oak Leaf Cluster valorous unit award. The regulations direct that lay evidence “consistent with the circumstances, conditions or hardships of such service” should be accepted as sufficient proof of service connection. 38 C.F.R. § 3.304(d). The Veteran testified that he injured his neck in a hard helicopter landing during his combat service. That injury and a failure to report the injury to medical personnel in a combat zone is consistent with the Veteran’s combat service, particularly in light of his personal bravery and demonstrated devotion to mission and country. The fact of an in-service neck injury is established. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a neck disability because no VA examiner has opined whether the Veteran’s current neck disability is related to his active service to include the in-service injury to his neck during combat. 2. Entitlement to service connection for migraine headaches including as secondary to a neck disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for migraine headaches because no VA examiner has opined regarding whether the migraines are related to his active service or whether the migraines are secondary to his (allegedly service-connected) neck disability. An opinion on direct service connection and whether the migraines have been caused by or aggravated by any service-connected conditions is necessary to decide this claim on its merits. 3. Entitlement to an initial evaluation in excess of 30 percent disabling for service-connected PTSD is remanded. The Veteran has indicated that his service-connected PTSD has worsened since his last VA examination in April 2013. The Veteran should be provided an updated examination to evaluate the PTSD. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (holding that, where the veteran claims a disability is worse than when originally rated and the evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination). 4. Entitlement to a TDIU. The Veteran has indicated that he is currently unemployed. His testimony and the other evidence of record is sufficient to raise the issue of entitlement to a TDIU in the context of a claim of entitlement to an increased rating for service-connected PTSD. Entitlement to TDIU is “part and parcel” of the determination of the appropriate rating for a disability. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009).   The matters are REMANDED for the following action: 1. Obtain any outstanding VA medical records from January 2013 to the present. This would include: Boise VA Medical Center from January 2013 until the Veteran relocated in 2015; and 2015 to the present from Puget Sound Health Care System (including Mount Vernon and Lake City CBOC’s). 2. Obtain the Veteran’s medical records from 2015 to the present from the Bellingham Vet Center. 3. Send the Veteran notice of the evidence needed to substantiate a claim for a total disability rating based on individual unemployability (TDIU) and ask him to complete VA Form 8940. Advise him he should submit any records he can obtain concerning the personnel actions against him from his last employer. 4. DO NOT SCHEDULE THE FOLLOWING EXAMINATIONS until all the above listed VA outpatient records have been obtained, to the extent possible. 5. Schedule the Veteran for an examination to determine the nature and etiology of any neck (cervical spine) disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including an in-service injury that occurred during a hard helicopter landing as described in his Board hearing testimony. The Veteran’s statements as to the circumstances of this injury must be accepted as credible. 6. Schedule the Veteran for an examination to determine the nature and etiology of any disability characterized by migraine headaches. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the in-service hard helicopter landing described by the Veteran. The examiner should also opine on the following: Secondary service connection – whether it is at least as likely as not (1) proximately due to the claimed neck condition, or (2) aggravated beyond its natural progression by the claimed neck condition. 7. Schedule the Veteran for an examination to determine the current severity of his service-connected PTSD. The examiner should discuss the effect of the Veteran’s PTSD on any occupational functioning and activities of daily living. MICHELLE KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Kerry Hubers, Counsel