Citation Nr: 1827366 Decision Date: 05/01/18 Archive Date: 05/14/18 DOCKET NO. 13-16 452 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to bilateral hearing loss. 2. Entitlement to service connection for bilateral eye disorder. 3. Entitlement to service connection for bilateral foot disorder. 4. Entitlement to service connection for right hand condition, previously claimed as carpal tunnel syndrome, right hand, to include as secondary to service connected left hand neuropathy. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Mine, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1966 to February 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In a March 2016 decision, the Board reopened the Veteran's claims for entitlement to service connection for an acquired psychiatric disorder, bilateral eye disorder, and a right hand disorder. The Board then remanded the reopened issues, as well as the Veteran's claim for a bilateral foot disorder, for additional development. The Veteran testified at a November 2015 videoconference hearing before the undersigned Veterans Law Judge (VLJ). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran has consistently asserted that his claimed disabilities stem from an in-service incident in which a stolen mail truck was driven through his platoon during a night march in early 1967 while he was stationed at Ft. Bliss, Texas. See, e.g., April 1976 VA Form 9; November 2008 Veteran statement; September 2014 Veteran statement; November 2015 hearing transcript. The Veteran has also asked the RO to attempt to verify the claimed incident. The RO sent a PIES request in September 2012 requesting a line of duty determination related to the claimed incident, which came back negative. The RO's inquiry incorrectly stated that the incident occurred in January 1966, but the Veteran did not enter service until December 1966 and the Veteran has alleged that the incident did not occur until January 1967. Thus, remand is necessary to attempt to verify the occurrence of the claimed accident. Additionally, while the Veteran was afforded VA examinations following the Board's prior remand, each was inadequate. The Veteran has asserted he developed posttraumatic stress disorder following the January 1967 mail truck accident. The April 2016 VA psychiatric examination did not address the Veteran's claimed PTSD, despite diagnosis of PTSD included in the Veteran's VA treatment records. Further, while the examiner gave a general opinion regarding secondary service connection, the examiner did not specifically address the Veteran's assertion that his psychiatric conditions are secondary to this service-connected hearing loss. The April 2016 foot examiner opined that there was no evidence of any foot condition or injury and there was no evidence of any chronic condition; however, February 1967 service treatment records show that the Veteran reported complaints of foot pain and numbness while standing and marching and subsequent VA treatment records show treatment for foot disorders, including peripheral neuropathy. The Veteran was afforded two right hand examinations in April 2016. A C&P examination gave diagnoses of degenerative arthritis and right hand median nerve neuropathy, but did not provide an opinion. A later VA examiner failed to provide an opinion as to the Veteran's assertion that his right hand condition is secondary to his already service-connected left hand condition. Although the April 2016 VA eye examiner opined that the Veteran's claimed bilateral eye disorders were not related to the asserted January 1967 mail truck accident, the examiner's opinion was based on a lack of evidence in the Veteran's record of the accident having occurred. Therefore, if the alleged January 1967 mail truck accident is confirmed following an adequate investigation by the RO, an addendum opinion would be warranted and the Board will defer a decision on this claim. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from private or VA health care providers. 2. Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims, to the claimed in-service stressor. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the RO. 3. Attempt to verify whether there is credible evidence to support the Veteran's alleged stressor. In addition to any other stressors identified by the Veteran pursuant to the development above, the RO should attempt to verify an incident in which the Veteran's platoon was hit by a stolen mail truck during a night march at Ft. Bliss, Texas, in or around January 1967. Such verification efforts should include contacting the National Personnel Records Center (NPRC), the U.S. Army and Joint Service Records Research Center (JSRRC), or any other agency deemed appropriate. Any additional action necessary for independent verification of the alleged stressor, including follow-up action requested by the contacted entity, should be accomplished. If the search for corroborating information leads to negative results, the RO should notify the Veteran, explain the efforts taken to obtain this information, and describe any further action to be taken. If any described stressor lacks sufficient information for verification purposes, such should be noted in a formal finding. 4. After the above development has been completed, and after any records obtained have been associated with the evidentiary record, the Veteran should be afforded a VA examination by a psychiatrist or psychologist to determine the nature and etiology of any diagnosed psychiatric disorder, to include PTSD. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. All necessary tests and studies, to include psychological testing, should be accomplished, and all clinical findings should be reported in detail. The VA examiner should offer an opinion with supporting rationale as to the following inquiries: a) The examiner should identify with specificity any acquired psychiatric disorder that is currently manifested, or that has been manifested at any time during the appeal period. b) If a diagnosis of PTSD is warranted, the examiner should identify the particular stressor(s) upon which the diagnosis is predicated. c) For any acquired psychiatric disorder other than PTSD that is currently shown or that has been manifested at any during the claim period, the examiner should opine whether it is at least as likely as not (i.e. probability of 50 percent or greater) that such disability was either incurred in service, is otherwise related to active military service, or was caused or aggravated by any other service-connected disability, to specifically include service-connected bilateral hearing loss. d) The examiner should specifically address the in-service notation of personality disorder, depression, and anxiety; and VA treatment records showing a diagnosis of personality disorders. If the Veteran has a personality disorder, the examiner should opine as to whether or not it increased in severity while he was on active duty by any "superimposed" disease or injury, resulting in additional disability. The complete rationale for all opinions should be set forth. 5. After the development in numbers 1, 2, and 3, above, has been completed to the extent possible, obtain an addendum medical opinion from an appropriate examiner regarding the nature and etiology of any diagnosed bilateral foot disorder. The claims folder, including a copy of this remand, must be made available to, and be reviewed by, the examiner. If, and only if, determined necessary by the examiner, the Veteran should be scheduled for another VA examination. The examiner should be asked to respond to the following inquiry, and all findings should be set forth in detail: a) The examiner should provide a medical opinion as to the likelihood that any diagnosed disorder is at least as likely as not (a 50% degree of probability or higher) related to some aspect of the Veteran's period of service. In doing so, the examiner is asked to comment on the February 1967 service treatment records showing complaints of foot pain and numbness while standing and marching and any subsequent VA treatment records showing treatment for foot disorders, including peripheral neuropathy. The examiner should offer a rationale for any opinion provided. If the examiner is unable to provide an opinion, then he or she should state so and why. 6. After the development in numbers 1, 2, and 3, above, has been completed to the extent possible, obtain an addendum medical opinion from an appropriate examiner regarding the nature and etiology of any diagnosed right hand disorder. The claims folder, including a copy of this remand, must be made available to, and be reviewed by, the examiner. If, and only if, determined necessary by the examiner, the Veteran should be scheduled for another VA examination. The examiner should be asked to respond to the following inquiry, and all findings should be set forth in detail: a) The examiner should provide a medical opinion as to the likelihood that any diagnosed disorder is at least as likely as not (a 50% degree of probability or higher) related to some aspect of the Veteran's period of service, or is related to his already service-connected left hand disability. In doing so, the examiner is asked to comment on the diagnoses of degenerative arthritis and right hand median nerve neuropathy given by the April 2016 C&P examiner. The examiner should offer a rationale for any opinion provided. If the examiner is unable to provide an opinion, then he or she should state so and why. 7. After the development in numbers 1, 2, and 3, above, has been completed to the extent possible, and if the claimed in-service mail truck accident is confirmed, obtain an addendum medical opinion from an appropriate examiner regarding the nature and etiology of any diagnosed eye disorder. The claims folder, including a copy of this remand, must be made available to, and be reviewed by, the examiner. If, and only if, determined necessary by the examiner, the Veteran should be scheduled for another VA examination. The examiner should be asked to respond to the following inquiry, and all findings should be set forth in detail: a) The examiner should provide a medical opinion as to the likelihood that any diagnosed disorder is at least as likely as not (a 50% degree of probability or higher) related to some aspect of the Veteran's period of service. In doing so, the examiner is asked to comment on the findings in the service treatment records that show that the Veteran complained of eye sensitivity to sunlight, and any other medical nexus evidence of record. The examiner should offer a rationale for any opinion provided. If the examiner is unable to provide an opinion, then he or she should state so and why. 8. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran and her representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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 (2012). _________________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).