Citation Nr: 19123726
Decision Date: 04/02/19	Archive Date: 03/29/19

DOCKET NO. 17-58 576
DATE:	April 2, 2019

REMANDED

Entitlement to an initial disability rating higher than 30 percent for an acquired psychiatric disorder, to include major depressive disorder, is remanded.

REASONS FOR REMAND

The Veteran had active service from May 2012 to March 2015.

This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA).  

Remand is necessary for additional development.  

First, it appears the Veteran applied for Social Security Administration (SSA) disability benefits.  See July 2018 SSA letter.  Evidence associated with her SSA disability claim is potentially relevant to her VA disability claim, and VA has a duty to assist her in obtaining all SSA records relating to her SSA benefits application.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(2).  

Second, the Veteran’s original claim for an acquired psychiatric disorder was for posttraumatic stress disorder (PTSD) associated with a March 2014 military sexual trauma (MST).  She underwent a VA examination for PTSD in September 2016 as part of the development of her claim, where she was diagnosed with Major Depressive Disorder (MDD) but found to not meet the diagnostic criteria for PTSD.  She subsequently underwent VA non-PTSD psychiatric examinations in July 2017, September 2017, February 2018, and January 2019, each of which noted the Veteran did not have any diagnosed mental disorder other than MDD.  However, the Veteran’s VA treatment records show she was diagnosed with PTSD by a VA psychologist in June 2017.  See also December 2017 VA mental health medication note (recording psychiatrist’s diagnostic impression as including “chronic PTSD, MST”).  As the Veteran’s claim is otherwise being remanded for development of additional evidence, the RO should schedule the Veteran for a new VA psychiatric examination that includes PTSD.

The matter is REMANDED for the following action:

1. Obtain and associate with the claims file all available SSA disability benefits records.  Document all efforts and any negative responses in the claims file.

2. DO NOT schedule VA examinations until the above records, have been obtained to the extent possible.

3. Schedule the Veteran for a VA psychiatric examination to obtain an opinion as to the nature, etiology, symptoms, and severity of any currently-diagnosed acquired psychiatric disorders.  All indicated tests and studies should be accomplished and the findings reported in detail.  The examiner must provide a comprehensive explanation for all opinions provided, and address the following:

(a.) Identify all currently-diagnosed acquired psychiatric disorders, and the current nature and severity of all symptoms; and

(b.) IF A DIAGNOSIS OF PTSD IS PROVIDED, the VA examiner should opine whether it is at least as likely as not the disorder began in or is otherwise etiologically related to the Veteran’s active military service, to include the March 2014 MST.

The VA examiner should specifically address the Veteran’s VA treatment records indicating clinical diagnoses of PTSD.

 

MICHELLE L. KANE

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	D. Leamon, Associate Counsel