Citation Nr: 20021817 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 19-30 266 DATE: March 27, 2020 ORDER Entitlement to service connection for a vestibular disorder is granted. FINDING OF FACT The Veteran has a vestibular disorder that is the result of an in-service traumatic brain injury (TBI). CONCLUSION OF LAW The criteria for service connection for a vestibular disorder have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from May 1996 to May 1999, March 2008 to April 2009, and May 2015 to June 2016. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2018 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). Service Connection – Vertigo The Veteran has asserted that he has vertigo as a result of his in-service TBI. Specifically, the Veteran reported that after sustaining his in-service TBI, he began experiencing regular lightheadedness, dizziness, spinning sensations, loss of balance, nausea, and headaches. The symptoms have continued ever since his TBI, occurring every few days for ten to twenty minutes. The Board notes that the Veteran is currently service-connected for a TBI. As such, the Board concedes that the TBI occurred during service as described. Service treatment records (STRs) are silent for complaints of, treatment for, or a diagnosis of vertigo, or symptoms associated with a later diagnosis of vertigo while the Veteran was in active service. However, the Veteran has reported that he first experienced symptoms while in active service and that his symptoms have continued since that time. The Veteran is competent to report when he first experienced symptoms of vertigo and that his symptoms have continued since service. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Moreover, the Board finds the Veteran to be credible in that respect. At an October 2018 VA examination, the Veteran reported that he began experiencing symptoms of dizziness, spinning, and vomiting following his in-service TBI in 2008. The examiner diagnosed benign paroxysmal positional vertigo and opined that the disability was less likely as not proximately due to or the result of his in-service TBI. In this regard, the examiner noted that while the Veteran reported symptoms of vertigo since service and was receiving current treatment for vertigo, there was no documentation of vertigo in the service medical records. The Board finds that the October 2018 VA medical opinion is inadequate to decide the claim. In this regard, the examiner failed to consider the Veteran’s lay statements regarding the onset and continuity of his symptoms. As the opinion is not adequate, it cannot serve as the basis of a denial of entitlement to service connection. Of record is a September 2018 private medical opinion regarding the Veteran’s vestibular disorder. In that opinion, it was opined that the Veteran’s vestibular disorder was at least as likely as not caused by his in-service TBI. In this regard, the private provider cited to a wealth of medical literature to support that conclusion. It was noted that vertigo, dizziness, and disequilibrium are common symptoms following a concussion and even a mild TBI. The Board finds that the September 2018 private medical opinion is adequate. In this regard, the examiner thoroughly reviewed and discussed the relevant evidence, considered the contentions of the Veteran, cited to relevant medical literature, and provided a supporting rationale for the conclusions reached. Further the examiner relied on their own expertise, knowledge, and training when drafting their report. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). At a September 2019 VA examination, the examiner reported that the Veteran did not have any signs or symptoms attributable to a peripheral vestibular condition or benign paroxysmal positional vertigo. Further, he reported that the DIX Hallpike test for vertigo was normal. Specifically, the test was negative for vertigo or nystagmus. A medical opinion was not provided. The Board finds that the September 2019 VA examination report is inadequate for adjudication purposes. In this regard, the examiner failed to consider all the other medical evidence of record showing the Veteran to have a current diagnosis of a vestibular disorder. As the examination report is inadequate, it cannot serve as the basis of a denial of entitlement to service connection. In summary, the Board concedes that the Veteran sustained TBI during active service. The Veteran has competently and credibly reported vertigo symptoms in service and since. The Veteran has a current diagnosis of a vestibular disorder. A private provider has linked the Veteran’s current diagnosis to his in-service TBI. There is no adequate medical opinion of record against the claim. Accordingly, the Board finds that the preponderance of the evidence is for the claim and entitlement to a vestibular disorder is warranted. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Ivan Franklin 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.