Citation Nr: 20022043 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 15-36 668 DATE: March 30, 2020 REMANDED Entitlement to service connection for a heart condition is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, somatic symptom disorder, and adjustment disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 1981 to December 1981 and in the U.S. Navy from May 1982 to May 1985. The psychiatric issue has been recharacterized given the nature of the Veteran’s claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a claim pursued by a claimant includes any diagnosis that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of records). In November 2018, the Veteran testified at a videoconference hearing before the undersigned. A transcript of the hearing is associated with the claims file. Upon review of the record, the Board finds that the claims must be remanded. The Board sincerely regrets the additional delay caused by this remand but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claims. 1. Entitlement to service connection for a heart condition is remanded. The Board finds that a remand is necessary for the RO to undertake additional development pertaining to the Veteran’s claim. The Veteran contends he suffers from a heart condition, which is related to his active service. The Veteran credibly testified that he was treated at Langley Air Force Base (AFB) in 1983 for an enlarged heart muscle and was prescribed nitroglycerin. See November 2018 Hearing Transcript, pp. 12 & 15. Unfortunately, the Veteran’s claims folders lack any medical treatment records from Langley AFB, nor has the RO made any attempts to associate those records with the Veteran’s claims folder. The Board finds that in light of the Veteran’s hearing testimony regarding his treatment of a heart condition during his time at Langley AFB in 1983, efforts should be made to obtain those treatment records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA is charged with constructive notice of medical evidence in its possession). The Board notes that the Veteran has not been afforded a VA examination with respect to his current claim for service connection for a heart condition. VA’s duty to assist includes providing a medical examination when it is necessary to decide a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159. 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). Here, a VA examination should only be scheduled for the Veteran regarding his heart condition claim if treatment records from Langley AFB is obtained showing treatment for a heart condition. 2. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Board finds a remand is warranted for further development of the Veteran’s claim, including to obtain missing records and for a new examination and etiological opinion. He contends he suffers from an acquired psychiatric disorder due to the stressors he experienced during his active service. The Veteran underwent a VA examination in April 2013, in which the examiner noted the Veteran did not have a diagnosis of PTSD or other mental disorders, that conforms with the DSM-IV criteria. The Veteran reported his first mental health treatment was in the 1980’s at the Epilepsy Center of Michigan, his last treatment was between 2010 to 2011 at the Henry Ford Hospital, and he was treated at Cottage Hospital around 2003 for depression and suicidality. He further reported two stressors. The first was a mid-air collision between two planes that resulted in the loss of six to seven pilots, to include the Veteran’s friend, named Lieutenant JG Johnson, and the second was an accident that involved another of the Veteran’s friends, in which the friend’s hand was ripped off when it was caught in a machine. The April 2013 examiner opined it was less likely than not that the Veteran’s condition incurred in or was caused by the claim in-service injury, event, or illness because there was no history of any diagnosis or treatment for PTSD in the Veteran’s claims folder. The Board finds the April 2013 opinion to be inadequate for adjudication purposes. The Veteran’s medical treatment records show he has a history of depression since 1992, as well as past medical history of PTSD. See November 2010 Medical Treatment Record – Non-Government Facility, pp. 20, 24, 26, 28; October 2012 Medical Treatment Record – Non-Government Facility, p. 4. Furthermore, additional treatment records that were not available to the April 2013 examiner also show a positive PTSD screening from November 2010 and diagnoses of somatic symptom disorder with predominant pain and adjustment disorder with depressed mood from April 2018. See August 2017 CAPRI, p. 249; August 2018 CAPRI, p. 43. Accordingly, a new examination is needed to adequately address the nature and etiology of any and all of the Veteran’s acquired psychiatric disorders. Additionally, in light of the Veteran’s report of mental health treatments at the Epilepsy Center of Michigan and the Cottage Hospital during his April 2013 VA examination and the absence of those records in the Veteran’s claims folder, the Board finds a remand is warranted to obtain any outstanding private medical records. On remand, the Veteran should be requested to authorize the release of those records, and the RO must make reasonable efforts to obtain the records including an initial request and at least one follow-up request if necessary. See 38 C.F.R. § 3.159(c)(1). All efforts to obtain private medical records must be documented. Finally, the Veteran testified that he was on disability with the Social Security Administration (SSA) at one time due to his depression. See November 2018 Hearing Transcript, p. 20. From a review of the records in the Veteran’s claims folder, it does not appear that the RO has attempted to obtain the Veteran’s complete SSA file. Once VA is put on notice that the Veteran is in receipt of SSA benefits, VA has a duty to obtain the records associated with that decision. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). The matters are REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder updated treatment records, including all treatment records from Langley AFB, Epilepsy Center of Michigan, and the Cottage Hospital. All attempts to obtain these records pursuant to 38 C.F.R. § 3.159(c) must be documented. 2. Contact the SSA to request and obtain the Veteran’s complete Social Security records, including all decisions and any medical records relied upon in making those decisions. 3. If treatment records from Langley AFB pertaining to a heart condition are obtained, then schedule the Veteran for a VA examination to determine the nature and likely etiology of his heart condition. The Veteran’s electronic claims file must be accessible for review by the VA examiner in conjunction with the examination and this review should be acknowledged in the report. Based upon a review of the relevant evidence of record, the VA examiner should offer the following opinion: (a.) Obtain a detailed history of any and all diagnosed heart condition(s) and identify any currently diagnosable condition associated with the Veteran’s heart condition. (b.) Whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s heart condition had its onset in or is related to service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his report must be taken into account in formulating the requested opinion. The examiner should address the Veteran’s service treatment records from Langley AFB concerning his enlarged heart muscle and the prescription of nitroglycerin, as well as the Veteran’s lay statements pertaining to the chest pains that he experienced. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Conduct any additional development necessary to attempt to verify the alleged stressors (as identified during his November 2018 Board hearing, in his April 2012 VA Form 21-0781, during his April 2013 VA examination report, and any other records), to include a mid-air collision that resulted in the death of six to seven lives in April 1983, the death of a pilot aboard the U.S.S. Nimitz who was killed while attempting to land his plane, and the loss of a hand of a fellow servicemember after it was caught in a machine. If necessary, the Veteran should be contacted to clarify the location, dates, and other details surrounding the facts of the stressor events, as well as to describe any additional stressors not listed above. 5. Thereafter, schedule the Veteran for a VA examination with an appropriate examiner to obtain a medical opinion concerning the etiology of any acquired psychiatric disorder, to include PTSD, depression, somatic symptom disorder, and adjustment disorder. A complete history from the Veteran should be obtained and recorded. The Veteran’s electronic claims file must be accessible for review by the VA examiner in conjunction with the examination and this review should be acknowledged in the report. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: (a.) Determine whether the Veteran may be diagnosed with a condition conforming to DSM-IV criteria. (b.) If the examiner diagnoses the Veteran with PTSD in accordance with DSM-IV, the examiner should indicate whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s PTSD was due to the reported in-service stressors. (c.) If the examiner concludes that the Veteran has an acquired psychiatric disorder(s) other than PTSD, the examiner should opine as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that the current psychiatric disorder(s) had its(their) onset during military service or is(are) causally related to such service, to include his claimed military stressors. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The examiner should address (1) the Veteran’s lay statements concerning his acquired psychiatric disorder symptoms; (2) the Veteran’s treatment records, which show a history of depression, positive PTSD screen, and diagnoses of somatic symptom disorder, and adjustment disorder; (3) any available SSA records; and (4) any available private treatment records from the Epilepsy Center of Michigan and the Cottage Hospital. (Continued on the next page)   The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. L. Park, 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.