Citation Nr: 1827563 Decision Date: 05/03/18 Archive Date: 05/14/18 DOCKET NO. 06-20 799 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for acquired psychiatric condition, to include posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD Michael J. O'Connor, Associate Counsel INTRODUCTION The Veteran had active service from February 1965 to November 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from April September 1997 and August 2005 rating decisions of the Regional Office (RO) in Houston, Texas. In a September 2010 decision, the Board denied the Veteran's claim for service connection for an acquired psychiatric disorder, to include PTSD. The Veteran appealed the Board decision to the Court. In an April 2012 Memorandum decision, the Court vacated the Board's decision and remanded the case for readjudication. In an October 2012 Remand, the Board recognized that VA initially developed and adjudicated the claim with regard to the issue as it was framed by the Veteran, i.e., a claim seeking service connection for PTSD. However, the evidentiary record also indicated diagnoses of anxiety disorder NOS, alcohol dependence, cocaine dependence, cannabis dependence, polysubstance abuse, and antisocial personality disorder. The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability which may reasonably be encompassed by the claimant's description of the claim, the reported symptoms and any other pertinent information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009 per curiam). In compliance with the Court's holding, the issue on appeal was modified as listed on the title page. In the 2012 Remand, the Board remanded the appeal to the RO for further development. Specifically, the Board remanded the appeal to the RO to obtain additional evidence, to include presentencing reports and treatment records; to attempt to verify the claimed stressors; to schedule the Veteran for a mental examination; and to readjudicate the claim. These actions have been completed. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Unfortunately, a remand is required in this case to properly adjudicate the Veteran's claim. The Veteran asserts that he has PTSD due to several stressors while serving as a lineman in Vietnam. One stressor, that his base was attacked and casualties were suffered, has been adequately supported by service records. The other claimed stressors have not been verified based on the information provided by the Veteran. In 2015, the Veteran, who is currently incarcerated, underwent an in-person examination with a VA examiner. However, the examiner did not provide a written opine regarding the Veteran's claimed condition due to the unavailability of the claims file and supporting evidence. However, it was stated "[o]nce records become available, please resubmit a 2507 for this examiner as the interview is already completed." In 2017, another examiner provided an opinion on the Veteran's claimed condition. The examiner did not conduct an in-person examination of the Veteran as the Veteran refused examination, nor did she have access to the interview report of the 2015 examination who apparently no longer works for VA. Based on the foregoing, the Board finds that the current medical evidence, in light of the stressor information, is inadequate to adjudicate the claim. As such, a new examination is required. Accordingly, the case is REMANDED for the following action: 1. Take appropriate steps to determine whether the interview report from the 2015 VA examination can be obtained. See VA examination report dated September 2015 implying that the interview results were documented. 2. If the 2015 examiner is available, forward such results to an appropriate examiner. The examiner should then provide an opinion as to whether the Veteran has symptomatology that meets the DSM-IV diagnostic criteria for PTSD. (If psychological testing is necessary to render this opinion, such testing should be undertaken.) If the examiner finds that the Veteran's meets the criteria for PTSD, the examiner must identify the specific stressor(s) underlying any PTSD diagnosis and comment upon the link between the current symptomatology and the Veteran's stressor(s). The examiner should also provide opinion as to whether the Veteran has manifested any other acquired psychiatric disorders other than PTSD, to include the previously diagnosed anxiety disorder NOS. For all other acquired psychiatric disorders other than PTSD, provide opinion as to whether it is at least as likely as not that such disorder(s) had its onset in service, or is causally related to service to include the verified base stressor of his Vietnam base coming under attack which resulted in casualties. A complete rationale should accompany each opinion provided, including an explanation that takes into account the record and pertinent medical principles. The examiner's rationale should include citation to pertinent evidence and/or medical principles relied upon to form that opinion. If an opinion cannot be made without resort to speculation, the examiner must provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. If the 2015 examination results are not available, offer the Veteran another examination explaining that his interview results are not available. If the Veteran refuses additional examination, the AOJ may use its discretion to determine whether any further opinion is needed. 3. After the above development has been completed, readjudicate the claim for entitlement to service connection for PTSD. If any benefit sought on appeal remains denied, furnish the Veteran a supplemental statement of the case and return the case 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. §§ 5109B, 7112 (2012). _________________________________________________ T. MAINELLI 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).