Citation Nr: 18156109 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 16-56 728 DATE: December 7, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post traumatic stress disorder (PTSD), anxiety disorder and depressive disorder. REASONS FOR REMAND The Veteran served on active duty from June 2004 through September 2009. This matter comes before the Board of Veterans’ appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Board acknowledges the receipt of a January 22, 2018 letter from the Veteran’s attorney concerning the Veteran’s VA examination of the Veteran for this claim. After stating that the claimant was raising for potential appellate review the competency of the examiner, the attorney requested the curriculum vitae (CV) of the examiner. He also asked that he be given a copy of the engagement letter or that inquiry be made of the examiner. The Board declines to provide the information requested in the letter. The duty to assist requires the VA to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate his claim for benefits. 38 U.S.C. § 5103A(a). The attorney’s request is not a reasonable one because (1) the VA examiner was a PhD psychologist; and (2) the VA benefits from a rebuttable presumption that it has properly chosen a person who is qualified to provide a medical opinion in a particular case. Parks v. Shinseki, 716 F.3d 581, 585 (Fed. Cir 2013) citing to Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011). To rebut the presumption, there must be clear evidence such as an irregularity in the process, such as a cardiologist providing a psychiatric opinion, which is not the case here. It is noted that the Veteran’s representative has not directly challenged the VA examiner’s competency or qualifications. It is further noted that the presumption of competency is not to be confused with whether an examination report is adequate; the adequate of the VA examination report is discussed below. The attorney’s request for the engagement letter is further not a reasonable request as he has not identified how this is relevant to the appeal, to include substantiating the Veteran’s claim. The examination report and two supplemental reports have been provided to the attorney. It is the opinions expressed in those reports which are evidence relevant to the resolution of the claim, not communications between the VA and the examiner. The purpose of the VA system of claims review is to ensure that veterans receive whatever benefits they are entitled to, not to litigate claims as if they were tort cases. Forshey v. Principi, 284 F.3d 1335, 1360 (Fed. Cir. 2002) (Mayer, C.J., dissenting). The Veteran is appealing the August 2013 denial of his claim for service connection for his acquired psychiatric disability, to include PTSD. The elements of service connection for PTSD are (1) medical evidence diagnosing the condition; (2) medical evidence linking current symptoms with an in-service stressor: and (3) credible evidence that the in-service stressor occurred. 38 C.F.R.§ 3.304(f). The Veteran submitted a statement that, while serving in Iraq, he was in camp during a mortar attack and helped recover the body of a soldier killed in the attack. Prior to May 2015, the Veteran was diagnosed with anxiety at the VA Medical Center (VAMC) in San Diego. In May 2015, a VA psychologist examined the Veteran and reported that the in-service stressor reported by the Veteran was adequate to support a diagnosis of PTSD. 38 C.F.R. § 3.304(f)(3). However, the examiner, after finding the Veteran met 7 of 8 diagnostic criteria for PTSD, diagnosed the Veteran with unspecified depressive disorder, not PTSD. After doing so, the examiner opined that the Veteran’s depressive disorder was less likely than not incurred in or caused by his military service. The Board finds that the examiner’s opinion concerning the etiology of the depressive disorder was inadequate because the examiner’s conclusion was not adequately supported by analysis. An adequate medical opinion should support its conclusions with an analysis the Board may consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). An adequate medical opinion must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In March 2018, the Veteran was examined by a private psychologist who diagnosed the Veteran with PTSD. The Board finds the opinion of the private psychologist inadequate because it lacks the factual detail and discussion necessary to support that he meets the criteria for a diagnosis of PTSD in accordance with the DSM-V. Stefl, supra; Nieves-Rodriguez, supra. The examiner merely checked boxes and provided minimal written discussion of medical history and clinical findings. It is further unclear if the evaluation was based on in-person examination or interview only. The examiner indicated that the Veteran had experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury. However, she did not indicate what the event was, how she learned of the event or how the Veteran was involved. Most of the written discussion was spent addressing the severity of the Veteran’s mental health problems and chronically evidence of record, rather than providing any meaningful discussion or explanation as to how the diagnostic criteria for PTSD are met. Given (1) the inadequacy of the VA medical opinion concerning the etiology of the diagnosed depressive disorder; (2) the inadequacy of the private medical opinion diagnosing PTSD; and (3) the conflicting opinions of the two psychologists, the Board finds that this matter should be remanded for a new examination. See Barr v. Nicholson, 21 Vet. App. 303, 321 (2007) (Once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, the examination provided must be an adequate one.) The matter is REMANDED for the following action: 1. Obtain all pertinent updated treatment records and associate them with the claims file. The VA examiner reported reviewing treatment records from the VAMC in San Diego, but there are no such records in the claims file. 2. Schedule the Veteran for a new examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, to include whether he meets the DSM-V criteria to support a diagnosis of PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If the Veteran is diagnosed with an acquired psychiatric disorder other than PTSD, the examiner should opine on whether any of these conditions had its/their onset in service or is/are otherwise related to service to include any injury, event, or disease. (Continued on the next page)   3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Mucklow, Associate Counsel