Citation Nr: 20003453 Decision Date: 01/15/20 Archive Date: 01/14/20 DOCKET NO. 15-12 819 DATE: January 15, 2020 ORDER Service connection for right shoulder arthritis is granted. REMANDED Service connection for an acquired psychiatric disorder, to include Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) is remanded. Service connection for eye condition is remanded. FINDING OF FACT The Veteran’s right shoulder arthritis was noted in service and has demonstrated continued symptomology since active service. CONCLUSION OF LAW The criteria for service connection for right shoulder arthritis have been met. 38 U.S.C. § 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1976 to February 1980. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in October 2019. A transcript of the hearing has been associated with the file. The issue of entitlement to service connection for lung condition was addressed in the March 2015 statement of the case (SOC). However, the Veteran specifically declined to appeal this claim to the Board in his substantive appeal. See March 2015 VA Form 9 (“I am only appealing these issues: service connection for right shoulder, service connection for PTSD, and service connection for eye condition). Thus, the issue of service connection for lung condition will not be addressed in this decision. The evidence of record demonstrates that the Veteran has been diagnosed with PTSD, and depression. As such, the Board has recharacterized the issue of entitlement to service connection for PTSD to include all acquired psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that although a veteran may only seek service connection for PTSD, the claim “cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed”). 1. Service connection for right shoulder arthritis is granted. The Veteran contends that his right shoulder arthritis is due to service. Certain chronic diseases will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. The Veteran’s right shoulder arthritis was not shown as chronic (reliably diagnosed) in service or within a presumptive period, and did not manifest to a compensable degree within a presumptive period. It was; however, noted in service, and there is continuity of symptomatology since service that is attributable to the right shoulder arthritis. The Veteran has a current diagnosis of moderate degenerative changes of the right shoulder. Although no treatment records exist from during the applicable presumptive period, the Board finds that the Veteran continued to experience the same symptoms from the time of his in-service injury. The Veteran is competent to report that he experienced symptoms of shoulder pain during that period, but did not seek treatment because of his fear of doctors. His testimony is credible and entitled to probative weight, as it is consistent with other evidence of record which shows his shoulder pain is etiologically related to his arthritis. As continuity of symptomology for a chronic disease has been shown, service connection for right shoulder arthritis is granted. REASONS FOR REMAND 1. Service connection for an acquired psychiatric disorder, to include Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) is remanded. The Veteran is seeking service connection for an acquired psychiatric disorder to include PTSD and depressive disorder. His service records are silent for any psychiatric disorders. His VA treatment records show that the Veteran has been treated for both PTSD and depressive disorder. The record does not contain any competent medical opinion as to the etiology of these conditions or the criteria used to diagnose them. The Veteran described his in-service stressor to be witnessing a soldier’s body on the ground after committing suicide. Because the file contains evidence of a current disorder, evidence of an in-service event, and an indication of association between the two, but insufficient competent medical evidence to support a decision, the Veteran is entitled to a VA medical examination. See McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006); 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). Furthermore, the record contains insufficient information to corroborate the Veteran’s in-service stressor. The Veteran testified that his in-service stressor occurred in 1976. See Hearing Testimony pg. 9. Therefore, further investigation of the in-service stressor is necessary. 2. Service connection for eye condition is remanded. Service treatment records reflect that the Veteran had a left eye injury with a noted diagnosis of cornea abrasion. VA treatment records show tears/breaks in the right general retinal area. The Veteran was afforded a VA examination in July 2013, wherein the examiner noted that the Veteran currently has bilateral cataracts, and that such diagnosis is age related rather than secondary to the Veteran’s diagnosed diabetes. The Veteran testified that his eye condition is the result of his in-service left eye injury which worsened over time. The Board finds the July 2013 VA examination is inadequate to adjudicate this claim as it does not address the Veteran’s lay contentions above. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (2006) (holding that a medical examination is inadequate if the examiner fails to consider whether the veteran’s lay assertions presented sufficient evidence of the etiology of his claimed disability). Therefore, the Board finds a remand is necessary in order to obtain another VA medical opinion. The matters are REMANDED for the following action: 1. To the extent possible, given the information provided by the Veteran, investigate the Veteran’s reported in-service stressors between February 1976 and February 1980, his dates of service as recorded on his DD 214, with specific focus on 1976. If this cannot be accomplished or if the investigation yields negative results, inform the Veteran and document the record accordingly. 2. Schedule the Veteran for an examination to determine the nature and etiology of any diagnosed acquired psychiatric disorder, including PTSD and depressive disorder. For each diagnosed disorder, if any, the examiner should provide an opinion as to whether the disorder was at least as likely as not (50 percent or greater probability) caused by or aggravated by the Veteran’s active service. A rationale must be provided for each opinion given. 3. Return the Veteran’s claims file to the July 2013 VA examiner for an addendum opinion regarding his eye condition. If the January 2014 VA examiner is unavailable, the addendum opinion should be rendered by another appropriate medical professional. After reviewing the complete record, the examiner should: a. Opine as to whether it is at least as likely as not (50 percent probability or greater) that his eye condition was caused by or otherwise related to his active duty service and explain why. b. In rendering an opinion, the examiner is asked to discuss the Veteran’s lay contentions that his eye condition is related to a basketball injury of his left eye in service. The Veteran has the right to submit additional evidence and argument on the matter or matters 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. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Russell, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.