Citation Nr: 1823749 Decision Date: 04/19/18 Archive Date: 04/26/18 DOCKET NO. 14-27 853 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: California Department of Veteran Affairs ATTORNEY FOR THE BOARD A. M. Williams, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to March 1973. His decorations include the Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran requested a video conference hearing on his Form 9 dated July 2014. He subsequently withdrew his request for a hearing in a letter to the Board dated November 2015. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). First, the Veteran has PTSD listed on his June 2015 Loma Linda VA HCS Problem List, and was referred to Trauma Recovery Services (TRS) for PTSD treatment. Second, the Veteran earned the Combat Action Ribbon, and thus his event in service is presumed. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). Third, the record indicates that the claimed PTSD may be associated with the established event in service. Specifically, as the Veteran explained in his October 2013 VA examination, his ship fired upon and destroyed enemy aircraft off the coast of Vietnam, and before the attack he was told that if the ship was destroyed, he should expect to become a prisoner of war. Although no mental health diagnosis was found by the October 2013 examiner, the subsequent June 2015 listing of PTSD by a treating VA clinician warrants a new examination and opinion. As the appeal is being remanded for development, the RO should ask the Veteran to identify any additional, pertinent medical treatment that he has received for his claimed PTSD, and take appropriate measures to obtain those records. Any additional, pertinent VA treatment records should either be made accessible electronically or be printed and added to the file. See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611 (1992); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran's pertinent medical history). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran and ask that he identify any outstanding VA and non-VA records pertaining to his PTSD that are not already of record. The RO should take appropriate measures to request copies of any outstanding records of pertinent VA or private medical treatment and associate them with the claims file. Any negative response should be in writing and associated with the claims file. 2. Notify the Veteran that he may submit additional lay statements from himself and from other individuals who have first-hand knowledge of the nature and onset of his acquired psychiatric disorder. He should be provided an appropriate amount of time to submit this lay evidence. 3. After physically or electronically associating any pertinent, outstanding records, the Veteran should be scheduled for an appropriate VA examination by an examiner other than the October 2013 VA examiner to determine the nature, extent, onset and etiology of any acquired psychiatric disorder found to be present. The claims folder should be made available and reviewed by the examiner. All indicated studies should be performed, and all findings should be reported in detail. The examiner should provide a diagnosis of the Veteran's acquired psychiatric disorder(s). If the examiner does not concur with the June 2015 VA clinician's finding of PTSD, then the examiner should explain why. For each diagnosed acquired psychiatric disorder, the examiner must opine as to whether it is at least as likely as not that the Veteran's acquired psychiatric disorder is related to or had its onset during service. For PTSD, the examiner should state 1) whether there is medical evidence of a diagnosis, and 2) whether there is a link between current symptoms and an in-service stressor. For PTSD regarding fear of hostile military activity, the examiner should state 1) whether the claimed stressor is adequate to support a diagnosis of PTSD, and 2) whether the Veteran's symptoms are related to the claimed stressor. In offering each of these opinions, the examiner should consider the Veteran's competent lay statements, the October 2013 VA examination report, and the June 2015 VA clinician's finding of PTSD. The examiner should give a reasoned explanation for all opinions provided. If the examiner is unable to provide a medical opinion, then he or she should provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. All findings and conclusions should be set forth in a legible report. 4. Then readjudicate the appeal. If the claim remains denied, issue a supplemental statement of the case to the Veteran and provide an opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. 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.A. §§ 5109B, 7112 (West 2014). ____________________________________________ DAVID GRATZ Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs