Citation Nr: 20005016 Decision Date: 01/22/20 Archive Date: 01/22/20 DOCKET NO. 13-28 147 DATE: January 22, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1972 to September 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared before the undersigned during a hearing in February 2014. The Veteran contends that his experiences in service, particularly being harassed, assaulted and punched in the face, are the cause of his PTSD. He stated that he reported his assaults but nothing was done. VA has a heightened notification obligation when a service connection claim for PTSD is based, in some part, on a claim of in-service personal assault. In these instances, VA must (1) notify the Veteran of alternative forms of evidence that may serve to corroborate his account, to include the opinion of a medical professional, (2) suggest other potential sources of evidence, and (3) assist the Veteran in submitting evidence from alternative sources by providing additional time for such submission after an adequate notice letter has been provided. See 38 C.F.R. § 3.304(f)(5); see also Menegassi v. Shinseki, 638 F.3d 1379 (Fed. Cir. 2011); Gallegos v. Peake, 22 Vet. App. 329 (2008). The evidence of record does not show the Veteran received the required notice and VA form 21-0781A, which is designed to report trauma from a personal assault. Thus, a remand is required to provide appropriate notice. In addition, the Veteran was provided VA examinations in July 2015 and February 2016. A July 2015 examination diagnosed the Veteran with PTSD; however, a nexus opinion was not provided. Furthermore, the examination notes the Veteran’s specific stressor as personal assaults while in service but also marks “no” to the question regarding whether the stressor is related to personal assault and “yes” to the stressor being related to the Veteran’s fear of hostile military/terrorist activity, which is not supported by the record. A February 2016 examination found that the Veteran did not meet the criteria for a PTSD diagnosis and that it was less likely than not that the claimed condition was incurred in or caused by his service. However, this opinion did not provide reasoning as to why the July 2015 diagnosis of PTSD is invalid. Thus, the Board finds that a remand is necessary to obtain an addendum opinion that reconciles the contradictory medical examinations. The matters are REMANDED for the following action: 1. Send the Veteran a notification letter informing him of the information and evidence required to substantiate PTSD claims based on in-service personal assault or harassment in accordance with 38 U.S.C. § 5103(a), 38 C.F.R. § 3.159(b) and 38 C.F.R. § 3.304(f)(5). 2. THEN, obtain an addendum opinion from the February 2016 examiner (if not available, an appropriate clinician) that addresses whether it is at least as likely as not (50 percent probability or greater) the Veteran has met the diagnostic criteria for PTSD at any point during the appeal period (i.e. since July 2012). The clinician should specifically address the July 2015 VA examination that shows a PTSD diagnosis, as well as any other lay and medical evidence describing the Veteran’s relevant symptomatology. If the Veteran has met the criteria for a diagnosis of PTSD at any time during the appeal, the clinician should identify the stressor or stressors upon which the diagnosis of PTSD was made. Then, the clinician should identify any other acquired psychiatric disorders for which the Veteran has met the diagnostic criteria in the appeal period. For each diagnosis, the examiner should opine as to whether it is at least as likely as not related to the Veteran’s military service. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ariasaif, 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.