Citation Nr: 18123784 Decision Date: 08/03/18 Archive Date: 08/02/18 DOCKET NO. 15-08 752A DATE: August 3, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from October 1972 to August 1974. These matters come before the Board of Veterans’ Appeals (Board) from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2016, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. A transcript of the hearing is of record. These matters were previously before the Board in April 2017, when they were remanded for additional development. 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. 2. Entitlement to a TDIU is remanded. The evidence indicates there may be outstanding relevant VA treatment records. An April 25, 2018 VA treatment record indicates that the Veteran was to return for a follow up appointment after May 25, 2018. VA treatment records subsequent May 8, 2017 have not been associated with the claims file. Additionally, VA treatment records from March 10, 2010, January 23, 2013, June 19, 2013, June 20, 2013, August 14, 2013, August 29, 2013, March 13, 2018, April 4, 2018, May 9, 2018 indicate that non-VA records had been scanned into VistA Imaging. It does not appear that these records have been associated with the claims file. A remand to obtain the aforementioned records is required. A July 26, 2017 VA vocational rehabilitation record notes that the Veteran was discontinuing vocational work therapy because he had obtained a job. To date, the Veteran’s complete vocational rehabilitation folder has not been associated with the record. A remand to obtain those records is required. The April 2017 remand directed that appropriate steps be taken to verify the Veteran’s reported stressors. The Veteran has provided varying dates regarding when his stressors occurred. Specifically, in June 2017 correspondences he stated that his shipmate was burned in February or March 1973 and the man overboard drill occurred between January 1973 and August 1974. Nevertheless, he had previously reported that his shipmate had been burned between September 1972 and December 1972 and the man overboard incident occurred between December 1972 and August 1974. To date, RO only reviewed ship logs dated between January 1973 and March 1973, and did not review records for the entire period identified by the Veteran. Gagne v. McDonald, 27 Vet. App. 397 (2015). Additionally, the Veteran reported that his in-service motor vehicle accident occurred between January 1973 and August 1974 and that it was either the Norfolk or Virginia Beach Police Department that responded to the accident. To date, the RO has not attempted to obtain an accident report from the identified police departments. On remand, reasonable efforts should be made to obtain any accident report concerning the Veteran’s motor vehicle accident. The was provided a VA PTSD examination in January 2013. While the examiner noted that the Veteran was diagnosed with PTSD and polysubstance dependence, the examiner did not acknowledge or address the Veteran’s other diagnoses of record, to include bipolar disorder, major depressive disorder, mood disorder, cognitive disorder, impulse control disorder, and dysthymia. Accordingly, an addendum opinion is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). In July 2017, the Veteran submitted a statement indicating that he had been employed part-time for the last seven months. It is unclear whether this part-time employment is substantially gainful. The Board notes that at present the Veteran does not have any service connected disabilities. Nevertheless, to avoid the possibility of the need for a future remand, employment information from his current and former employers should be requested. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records dated since May 8, 2018 as well as the VistA Imaging records referenced in the March 10, 2010, January 23, 2013, June 19, 2013, June 20, 2013, August 14, 2013, August 29, 2013, March 13, 2018, April 4, 2018, May 9, 2018 VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Ask the Veteran to fully complete a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, to include detailing all recent education and training as well as all full-time or part-time employment. 3. Obtain and associate the Veteran’s complete VA vocational rehabilitation counseling folder, to include all evaluations and narrative reports. If the records are not available, the claims file should be annotated to reflect such and the Veteran notified of such. 4. Attempt to corroborate the Veteran's claimed stressor(s), as reported on his June 2017 VA Form 21-0781, January 8, 2013 VA PTSD examination, November 29, 1999 statement, and May 6, 1992 statement. Unless it is determined that there is not enough information to make an inquiry for reasons other than the time period identified by the Veteran, multiple requests should be submitted to the JSRRC related to the stressor event(s), each request encompassing a different 60-day period, to cover the period reported by the Veteran. 5. With any assistance required from the Veteran, request records from the Norfolk and Virginia Beach Police Departments regarding the Veteran’s reported motor vehicle accident. If any requested records are unavailable, the Veteran should be notified of such. 6. After the above is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's acquired psychiatric disorder claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine whether it is at least as likely as not (50 percent probability or greater) that any psychiatric disability diagnosed during the claim, to include bipolar disorder, major depressive disorder, mood disorder, cognitive disorder, impulse control disorder, and dysthymia, had its onset during service or is otherwise related to service. A complete rationale should be provided for all opinions and conclusions expressed. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs