Citation Nr: 18155340 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 15-18 425 DATE: December 4, 2018 REMANDED The issue of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and psychotic disorder, is remanded for additional development. REASONS FOR REMAND The Veteran served on active duty from August 1970 to September 1973. This appeal arose to the Board of Veterans’ Appeals (Board) from a December 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. A hearing before a Veterans Law Judge was scheduled for November 2018, however, the Veteran did not show for the hearing. Therefore, the request for a hearing is considered withdrawn. 38 C.F.R. § 20.704(d). The Board observes that the RO had originally adjudicated the Veteran’s claim as entitlement to service connection for PTSD. However, the medical evidence of record reveals a diagnosis of psychotic disorder, also noted as delusional disorder. Accordingly, the issue has been amended. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). The Veteran is seeking service connection for an acquired psychiatric disorder, to include PTSD and psychotic disorder, which he attributes to his active duty service. Establishing service connection for an acquired psychiatric condition requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The Veteran asserts that VA did not meet its duty to assist. The VA’s duty to assist requires the VA to make reasonable efforts to assist a claimant in securing evidence necessary to substantiate their claim for VA benefits. See 38 U.S.C. § 5103A; 38 C.F.R § 3.159(c). The record demonstrates that the Veteran was hospitalized for psychiatric evaluation at the Franklin Regional Hospital. However, the RO did not request the Veteran’s medical records from the Franklin Regional Hospital. In addition, the Veteran’s attorney advised the RO that the Veteran was hospitalized for psychological treatment for six weeks, but did not know where he was hospitalized. The RO did not make an effort to obtain information regarding that hospitalization and treatment. The medical records from Franklin Regional Hospital, as well as the medical records from the unknown hospital at which the Veteran was provided psychological treatment, are highly relevant to the Veteran’s claim, and reasonable efforts should have been made to obtain those records. See 38 U.S.C. § 5103A(b); 38 C.F.R § 3.159(c)(1). Therefore, the VA failed to meet its duty assist when it did not make reasonable efforts to obtain the Veteran’s private medical records directly related to psychological treatment. Id. Although the RO previously scheduled the Veteran for a VA examination, and the Veteran did not report for that appointment, if additional relevant medical documentation is received the RO should schedule a new examination for the Veteran in order to satisfy the duty to assist. See 38 U.S.C. § 5103A(d); 38 C.F.R § 3.159(c)(4). Based on a letter received from the Veteran’s attorney, the Veteran has been permanently placed in a nursing home due to his worsening mental impairment. Therefore, if the Veteran fails to report for the examination a VA examiner should review the file and provide an opinion based on review of the file. The matter is REMANDED for the following action: 1. Ask the Veteran and his attorney to provide the names and addresses of any medical provider, VA or private, who has treated him for a psychiatric condition. After securing any necessary releases, the RO should request any relevant records identified that are not duplicates of those already contained in the claims file. Additionally, obtain VA treatment records dating from November 2014 to the present. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After associating any additional records with the claims file, if additional relevant records are received, schedule the Veteran for a VA mental disorders examination to determine the nature and etiology of his psychiatric conditions. All diagnostic testing deemed to be necessary by the examiner should be accomplished. The examiner should provide the following: (a.) Identify all currently diagnosed mental health disabilities. In doing so, the examiner should note that the term “current” means occurring at any time during the pendency of the Veteran’s claim; i.e., from July 2014 onward. The psychiatric disorder need not be present at the time of the examination; rather it is sufficient if it previously existed during the pendency of the claim and then resolved prior to the examination. (b.) The Board notes that the record shows past diagnosis of psychotic disorder. This disorder, along with PTSD, should be considered and discussed, in addition to any other disorders that may be found. If any specific disorder is ruled out, a complete explanation must be provided. That explanation should include a discussion of all the pertinent evidence of record, to include lay evidence. So, for example, if the examiner were to find that PTSD is not a current disability, then the explanation should include a discussion of the medical records, prior VA examinations, as well as the Veteran’s lay statements regarding his condition. If the examiner determines that any prior diagnosis cannot be validated, she or he should explain why. (c.) With respect to each diagnosed psychiatric disability, the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the disability arose during service or is otherwise related to any incident of service. Please explain why or why not. A rationale for any opinions expressed should be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.).  3. If the Veteran fails to report for the examination a VA examiner should review the file and provide an opinion based on review of the file. 4. In drafting the request for a VA opinion, direct the VA examiner to consider that the Veteran is a combat Veteran and the examiner must accept as sufficient proof of service-connection satisfactory lay or other evidence of service incurrence or aggravation of the claimed illness if that evidence is consistent with the circumstances, conditions, or hardships of service in combat, notwithstanding the fact that there is no official record of such incurrence or aggravation in service, and shall resolve every reasonable doubt in favor of the Veteran. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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. [CONTINUED ON NEXT PAGE] S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Temple, Associate Counsel