Citation Nr: 18106914 Decision Date: 06/01/18 Archive Date: 05/31/18 DOCKET NO. 14-30 705 DATE: June 1, 2018 ORDER Entitlement to service connection for a chin scar is granted. REMANDED Entitlement to service connection for residuals of a traumatic brain injury is remanded. FINDING OF FACT The Veteran has a scar on his chin as a result of an injury to his chin during active service. CONCLUSION OF LAW The criteria for service connection for a chin scar are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1980 to April 1983. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision. In January 2017, a new VA Form 21-22 was received at the RO appointing the representative listed on the title page above. The Board recognizes this change in representation. In February 2017, the Veteran and another witness testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Veteran has also perfected an appeal of an November 2014 rating decision that found the Veteran had not submitted new and material evidence needed to reopen a claim for entitlement to service connection for posttraumatic stress disorder. This claim has been certified to the Board. The Veteran has requested and is awaiting the scheduling of a video-conference hearing before the Board on this claim. As such, it will be addressed in a separate Board decision. Service Connection Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “medical nexus” between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303(a). 1. Entitlement to service connection for a chin scar. The Veteran asserts that his chin was lacerated during active service, which resulted in a scar. Specifically, he asserts that a fellow service member struck his chin with a rifle in December 1981, causing a laceration and requiring sutures. The Board concludes that the Veteran has a current chin scar that resulted from an in-service injury. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a). The Veteran underwent a September 2013 Scars/Disfigurement Disability Benefits Questionnaire (DBQ). Upon examination, the VA examiner found that the Veteran did not have a facial scar. The examiner stated that upon palpation, a scar could not be appreciated because the scar may have faded. However, a May 2014 VA treatment record shows that an examiner observed a scar on the Veteran’s chin, described as one-centimeter and “fairly visible.” The Board finds the conflicting evidence with regards to the Veteran’s diagnosis is in equipoise, and therefore resolves reasonable doubt in the Veteran’s favor to find that a chin scar was diagnosed during the pendency of the Veteran’s appeal. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran’s service treatment records (STRs) contain a Triage Note of Acute Medical Care dated December 30, 1981, indicating that the Veteran had three to six sutures in his chin. However, an accompanying Emergency Report is illegible. Also of record is a progress note from the US Army Health Clinic dated December 30, 1981, noting that the Veteran was directed to avoid shaving the area of the wound for five days. He was to follow up with Dr. Rockwell at the TMC. As such, the Veteran suffered an injury to his chin during service. With respect to the third element, a nexus between the in-service injury and the chin scar diagnosed during the pendency of the claim, the Veteran has reported that the scar on his chin has been present since his in-service injury. The Veteran statements as to his observations of a scar on his chin since service are competent and the Board finds him to be credible in this regard. Thus, the Board finds there is a nexus between the Veteran’s current chin scar and his active duty service. Service connection for a chin scar is warranted. REASONS FOR REMAND 2. Entitlement to service connection for residuals of a traumatic brain injury. The Veteran asserts that he sustained a traumatic brain injury when he was struck on the chin with a rifle by a fellow service member. As noted above, the Veteran’s STRs contain a Triage Note of Acute Medical Care dated December 30, 1981, indicating that the Veteran had three to six sutures in his chin. However, an accompanying Emergency Report is illegible. Also of record is a progress note from the US Army Health Clinic dated December 30, 1981, noting that the Veteran was directed to avoid shaving the area of the wound for five days and was to follow up with Dr. Rockwell at the TMC. On remand, efforts should be undertaken to ensure that the Veteran’s complete service treatment records related to this injury have been obtained. Further, post-service treatment records show that the Veteran has complained of headaches. He is also treated for psychiatric problems. On remand, he should be scheduled for an appropriate VA examination to determine if he has any head injury residuals associated with being struck on his chin during service. Lastly, a VA Progress Note dated May 26, 2017 reveals that the Veteran receives disability benefits from the Social Security Administration (SSA). To the extent that these SSA disability records may be relevant to the claim, VA is obliged to attempt to obtain and the supporting documents on which the decision was based and consider those records in adjudicating this appeal. Hayes v. Brown, 9 Vet. App. 67 (1996). The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records, dated from August 2017 to the present. 2. Obtain the Veteran’s complete service treatment records, to include all clinical records, all records related to his emergency room visit for an injury to his chin on December 30, 1981, and all follow-up records related to his chin injury at the TMC. 3. Obtain from the SSA a copy of any decision regarding the Veteran's claim for disability benefits, as well as copies of all medical records underlying that determination. 4. After the above development is completed, schedule the Veteran for an examination by an appropriate clinician to determine if he has any current head injury residuals as a result on his in-service injury. The examiner should provide an opinion as to whether it is at least as likely as not (50% or greater probability) that the Veteran has any current head injury residuals (i.e., headaches, cognitive impairment, psychiatric problems, etc.) as a result of his in-service injury on December 30, 1981. In providing this opinion, the examiner should consider the following: • The Veteran’s statement that he sustained a traumatic brain injury when he was struck on the chin with a rifle by a fellow service member; • The STRs containing a Triage Note of Acute Medical Care dated December 30, 1981, indicating that the Veteran had three to six sutures in his chin; and • The post-service treatment records showing that the Veteran is treated for headaches and psychiatric problems. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel