Citation Nr: 20004397 Decision Date: 01/17/20 Archive Date: 01/17/20 DOCKET NO. 17-48 561 DATE: January 17, 2020 REMANDED Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). is remanded. Entitlement to service connection for a right hand disorder is remanded. Entitlement to service connection for a right wrist disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1995 to April 1998. He served in the United States Navy. In October 2019, the Veteran appeared at a Board hearing and testified before the undersigned Veterans Law Judge. Regarding all claims on appeal, VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C.§ 5103A (2014); 38 C.F.R. § 3.159(c) (2018). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records. 38 C.F.R. § 3.159(c)(2). The Veteran’s service personnel records are of record, however, there is evidence that they might be incomplete. At the October 2019 Board hearing, the Veteran stated that he did not have a complete copy of his personnel records. Upon review of the record, it appears the Veteran’s personnel records may also be missing aside from what was submitted by the Veteran. There has been no attempt by the RO to obtain his military personnel records. The Board finds that attempts should be made to obtain the Veteran’s available military personnel records as they might contain relevant evidence to support the Veteran’s claims. 1. Entitlement to service connection for a psychiatric disorder, to include PTSD, is remanded. First, remand is required to attempt to obtain additional records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2014); 38 C.F.R. § 3.159 (c) (2018). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency. 38 C.F.R. § 3.159 (c)(2). This also includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159 (c)(1). The Veteran submitted a December 2017 letter from a private psychologist, Dr. A.E.B. who stated that he had met with the Veteran a total of 15 times. Dr. A.E.B.’s letter appeared on Westside Psychological Services letterhead. However, there are no treatment records from Westside Psychological Services or from Dr. A.E.B. in the Veteran’s claims file. Therefore, it appears there may be missing records. Second, remand is required for a new VA examination. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). At the October 2019 Board hearing, the Veteran testified that his life went down the tubes after discharge from service due to his PTSD symptoms. The Veteran testified that he had good marks in service until he started having medical and medical issues and asked for help, after which time his performance evaluations started to go down. VA nad private medical records provided diagnoses of PTSD and depressive disorder. During a December 2015 private psychologist session with Dr. E., the Veteran was noted to suffer from military related PTSD symptoms, which were a direct result of the trauma of his experiences during his tour of duty. Specifically, Dr. E. stated that the Veteran reported being hazed, and being on a submarine in the English Channel which became flooded were traumatic experiences for the Veteran. A January 2016 VA examination was conducted. During the examination, the Veteran was noted to have diagnoses of 1) ADHD, childhood onset, inattentive type; and 2) deferred, probable mixed personality disorder. The Veteran claimed PTSD due to “hazing” during military service, including being punched in the chest, long hours, and unreasonable task loads. The examiner concluded that there was no current Axis I diagnosis that could be linked to active duty military service without resort to mere conjecture. The examiner stated that the Veteran’s current symptoms do not appear to be related to previous diagnosis of adjustment disorder, and the mention of PTSD from the private therapist was without clear delineation or symptoms warranting diagnosis. However, the examination report did not address depressive disorder and there was incomplete evidentiary development which may be relevant to any medical opinion rendered. Therefore, as remand is necessary for a new VA examination. 2. Entitlement to service connection for a right hand disorder is remanded. 3. Entitlement to service connection for a right wrist disorder is remanded. Remand is required to obtain a VA examination regarding the etiology of the any right hand and/or right wrist disorders. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d) (2014); 38 C.F.R. § 3.159(c)(4) (2018). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). As to the Veteran’s claims for service connection for a right hand and right wrist disorders, the Veteran alleged that he fell on his right hand while he was on a submarine in the English Channel. The Veteran also stated that it was rough seas and the submarine was flooding. The Veteran asserted that when he fell, he went to the Corpsman and was told he had a strain and had it wrapped up. See March 2016 Notice of Disagreement (NOD). The Veteran alleged that since his fall in the submarine, he has not had full range of motion in his right wrist since. See March 2016 NOD. In a January 1998 STR note, it was documented that the Veteran had complained of and received treatment for multiple lesions to his right hand. During the October 2019 Board hearing, the Veteran testified that he experienced a slip and strain on a submarine, and he did not really have a choice but to just wrap it up. The Veteran further stated that since service, he still could not put his hand all the way back and did not have full motion in his right wrist. The Veteran testified that he experienced arthritic pain in his hand. Here, the Veteran has provided testimony of symptoms of a disability in his right hand and right wrist. Additionally, there is evidence that they may have been incurred in or related to service, to include a slip and fall on a submarine, and that the current symptoms and in-service event may be associated. Accordingly, remand is necessary for VA examinations to satisfy the VA's duty to assist. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. A specific request should be made for complete treatment records from the Portland VAMC from July 2017 through present. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. A specific request should be made for records from the Westside Psychological Services and/or Dr. A.E.B. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. Contact the Veteran and afford him the opportunity to identify the name of the submarine and approximate dates of the alleged incident involving his submarine flooding in the English Channel. 4. Contact the JSRRC, the National Archives and Records Administration (NARA), and/or any other appropriate entity to determine whether any records exist, including submarine/ship and deck logs, to support the Veteran’s claim that his submarine encountered an accident in the English Channel. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 5. After completing the above development, prepare a memorandum regarding a formal finding as to whether the Veteran was aboard a submarine which flooded while in the English Channel. 6. After all development has been undertaken, schedule the Veteran for a VA examination to assist in determining the nature and etiology of all psychiatric disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a detailed history of the alleged in-service events. It should be noted that the Veteran is competent to attest to observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (a.) Identify all psychiatric disorders previously diagnosed and currently diagnosed. If a previously diagnosed disorder is no longer present, the examiner must explain why and reconcile any conflicting medical evidence. Prior diagnoses included, but are not limited to: 1) PTSD; 2) ADHD; 3) persistent depressive disorder; 4) adjustment disorder; and 5) personality disorder. (b.) For each non-PTSD psychiatric disorder diagnosed, provide an opinion regarding whether it is at least as likely as not (50 percent probability or higher) that each disorder had its onset in, or is otherwise related to, active service. The examiner must address the Veteran’s lay statements and testimony regarding onset and continuity of symptoms and in-service events. (c.) With respect to PTSD, the examiner should first determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. The examiner must address the following: 1) the December 2015 private clinician notations of PTSD; 2) the Veteran’s STRs noting a) adjustment disorder, and b) personality disorder; 3) the January 2016 VA examination report; 4) the Veteran’s lay statements regarding his stressors, including a) being hazed during active duty, including being punched in the chest; and b) his submarine being flooded; and 5) the October 2019 Board hearing testimony. (d.) If a diagnosis of PTSD is deemed appropriate, the examiner must comment on the link between the current symptoms and any verified in-service stressor and/or personal assault. Based on the review of the claims file and the results of the examination, particularly the Veteran’s psychiatric history as elicited during the examination and as provided at the October 2019 Board hearing, the examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e., a probability of at least 50 percent or more) that the Veteran exhibited symptoms and behaviors consistent with behavioral changes expected to follow from the claimed personal assault, and if so, whether any of his current psychiatric diagnoses, are related to the alleged incident(s). 7. After any additional records are associated with the claims file, schedule the Veteran for a VA examination to assist in determining the etiology of all right hand and wrist disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a full history and/or description of his active service. (a.) For each currently diagnosed right hand and wrist disorder, the examiner must opine whether is it at least as likely as not (a 50 percent or greater probability) that the disorder manifested in or is otherwise related to the Veteran’s military service. The examiner must consider the Veteran’s 1) lay statements describing his in-service symptoms, 2) in-service incident of his submarine flooding, 3) his post-service symptoms; 4) the January 1998 STR notation of multiple lesions to the right hand and wrist; and 5) the October 2019 Board hearing testimony. 8. Notify the Veteran that it is her responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Nguyen, 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.