Citation Nr: 20009718
Decision Date: 02/05/20	Archive Date: 02/05/20

DOCKET NO. 19-09 652
DATE: February 5, 2020

REMANDED

Entitlement to compensation under 38 U.S.C. § 1151 for seizures and/or syncopal episodes is remanded.

REASONS FOR REMAND

The Veteran served honorably on active duty in the United States Army from March 1990 to March 1993.

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2018 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA).

Entitlement to compensation under 38 U.S.C. § 1151 for seizures and/or syncopal episodes is remanded.

The Veteran seeks compensation for additional disability which he has argued is caused by side effects of gabapentin medication that caused him to have syncopal episodes and/or seizures.  Although the record now contains both VA and non-VA medical treatment records from around the time the Veteran was hospitalized for syncopal episodes in July 2017, the Veteran’s various reports in those treatment records regarding the precise onset of his history of syncope vary substantially.  Some of his reports suggest they did not occur prior to his hospitalization, whereas others suggest that they first began more than 10 years earlier.  

Importantly, the July 2017 VA emergency department intake note, at which the Veteran was accompanied by his daughter, includes a statement from the Veteran that he first began experiencing these episodes six months earlier and that he was evaluated for possible syncope in Las Vegas, Nevada.  There is no evidence that VA has yet made reasonable efforts to obtain those treatment records.  As they could shed considerable light into the precise onset and cause of the Veteran’s claimed additional disability and would illuminate the specific medical history of his syncopal episodes, VA has a duty to attempt to obtain those records in connection with the Veteran’s claim.  

The matters are REMANDED for the following action:

1.  Ask the Veteran to complete a VA Form 21-4142 for the medical facility that evaluated him  for possible syncope around January 2017 in Las Vegas, Nevada.  Make two requests for the authorized records from any facility identified, unless it is clear after the first request that a second request would be futile.

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2.  After the above development, and any additionally indicated development to include consideration of whether an addendum opinion was warranted, has been completed, readjudicate the claim on appeal. If the benefit sought is not granted, furnish a supplemental statement of the case (SSOC) and then return the appeal to the Board, if otherwise in order.

 

 

KRISTY L. ZADORA

Acting Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	B. Whitelaw, 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.