Citation Nr: 19123774 Decision Date: 04/02/19 Archive Date: 03/29/19 DOCKET NO. 15-44 148 DATE: April 2, 2019 REMANDED Whether new and material evidence has been received to reopen a previously denied claim for service connection for a claimed left leg injury, to include a current disability of the left knee, is remanded. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a claimed right leg injury, to include a current disability of the right knee, is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to an increased (compensable) disability rating for current residuals of an in-service laceration of the posterior tibial area is remanded. REASONS FOR REMAND The Veteran enlisted in the Army National Guard in September 1979 and separated from that service in March 1984. Between these dates, he completed multiple periods of annual training, active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). In December 2018, he testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. Concerns Applicable to the Veteran’s Claims Generally According to the Veteran’s post-service VA medical treatment records, he receives monthly disability benefits from the Social Security Administration (SSA). Pursuant to its duty to assist the Veteran, VA must attempt to obtain relevant records from other Federal departments or agencies, including the SSA. See 38 C.F.R. § 3.159(c)(2). It is not clear from the record whether the Agency of Original Jurisdiction (AOJ) ever made a request to the SSA for the medical and other evidence relied on by the agency to determine that the Veteran was eligible for benefits. It is also unclear to what extent SSA considered the effects of the Veteran’s different claimed disabilities when awarding him benefits. Therefore, the medical and claims processing records maintained by the SSA could potentially be relevant to any of the issues in this appeal. On remand, the Agency of Original Jurisdiction (AOJ) should make an appropriate records request to the SSA. During the videoconference hearing, the Veteran testified that he regularly received medical and psychiatric treatment from a VA medical center. Some records from this facility have been associated with the claims file. The Veteran testified that he attended his most recent medical appointment approximately six months before the hearing – in other words, June 2018 – and his most recent psychiatry appointment in November 2018. The most recent available records date from September 2015. At the hearing, the Veteran’s attorney suggested that the Board should attempt to obtain copies of these records. On remand, the AOJ should make reasonable efforts to do so. Increased Rating for Current Residuals of an in-service Laceration of the Posterior Tibial Area To help decide this claim, the AOJ attempted to arrange an examination with a medical professional in private practice affiliated with a contracting service which provides such examinations for VA. According to a note in the file, this examination was cancelled because “the claimant does not have any transportation to attend appointments.” A separate note suggests that the reason for the cancellation was that the Veteran “prefers to be seen at the VA medical facility.” On remand, the AOJ should make another attempt to schedule this examination. Since the Veteran is apparently able to attend the medical and psychiatric appointments at his local VA medical center, the AOJ should attempt to schedule the examination there. If the examination cannot be scheduled at the VA medical center, the AOJ should explain in writing the reasons for that conclusion. If the examination must be scheduled elsewhere, the AOJ should make all reasonable efforts to ensure that the Veteran is notified of the date, time, and place of the examination. As his attorney explained at the hearing, the Veteran claims that each of his claimed disabilities is a secondary result of his service-connected laceration of the posterior tibial area. See 38 C.F.R. § 3.310. After the completion of the examination of this condition, the AOJ should review the file and consider the potential need for additional examinations or opinions concerning the etiology of the Veteran’s claimed service-connected disabilities. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file copies of all the Veteran’s VA treatment records since September 2015. 2. The AOJ should send a request to the Social Security Administration (SSA) for copies of all of the Veteran's records, not only medical records, but also all other SSA records, including but not limited to copies of the Veteran’s application for benefits and the SSA decision. The text of the AOJ’s request to the SSA, and any necessary follow-up requests, should make clear that the records requested include copies of the Veteran's application to the SSA and the SSA decision. If the requested records are found to be unavailable, this should be noted in the claims file and the Veteran should be notified that the AOJ could not obtain any records from SSA. 3. Schedule the Veteran for an examination with a qualified medical professional to determine the current severity of any current residuals of the Veteran’s in-service laceration of the posterior tibial area. If possible, the AOJ should schedule this examination to take place at the VA medical center where the Veteran attends his regular medical and psychiatric appointments. If the examination cannot be scheduled at the VA medical center, the AOJ should explain in writing the reasons for that conclusion. Wherever the examination is scheduled, the AOJ should make reasonable efforts to notify the Veteran of the date, time, and place of the examination. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. All indicated evaluations, studies, and tests should be accomplished and all findings reported in detail. Using the most current VA examination report form, the examiner should then describe the current severity of the Veteran’s in-service laceration of the posterior tibial area. 4. After completing the development required by parts one to three of these instructions, the AOJ should review the claims file and consider the potential need for further development to help decide the Veteran’s pending claims for service connection. The AOJ should specifically consider the potential need for new medical examinations or opinions to decide whether the Veteran is eligible for compensation for any of his claimed disabilities on the grounds that they are proximately due to, or the result of, the Veteran’s service-connected laceration of the posterior tibial area pursuant to 38 C.F.R. § 3.310. 5. The AOJ must ensure that the requested examination reports and medical opinions are in compliance with the directives of this remand. If any report is deficient in any manner, the AOJ must implement corrective procedures at once. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Nye, Associate Counsel