Citation Nr: 20022448 Decision Date: 03/31/20 Archive Date: 03/31/20 DOCKET NO. 14-18 063 DATE: March 31, 2020 ORDER New and material evidence having been received, the claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is reopened; to this extent only, the appeal is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and a major depressive disorder, is remanded. FINDING OF FACT 1. Service connection for PTSD was denied in a February 2000 rating decision on the basis that the claim was not well grounded (since there was no diagnosis of PTSD). 2. The Veteran filed a notice of disagreement for the February 2000 rating decision, but did not file a Substantive Appeal, VA Form 9; that decision therefore became final. 3. Evidence received since the February 2000 rating decision relates to unestablished facts necessary to substantiate the service connection claim for an acquired psychiatric disorder, to include PTSD. CONCLUSION OF LAW New and material evidence has been received, and the Veteran’s claim for service connection for PTSD is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from September 1967 to March 1969 and is in receipt of a Purple Heart medal. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Board notes that the issue on appeal was characterized as entitlement to service connection for PTSD. However, in light of the evidence of record, the Board has recharacterized the issue more broadly to ensure complete consideration of the claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). New and Material Evidence Service connection for PTSD was initially denied in a February 2000 rating decision. The RO noted that the Veteran’s VA treatment records were negative for PTSD, and there was no additional evidence submitted linking PTSD to service. A claim which has been finally denied may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). The evidence received since the February 2000 rating decision includes VA examinations in October 2006 and July 2012 showing a diagnosis of a psychiatric condition. The evidence is new as it was not previously considered and material as it pertains to an unestablished fact of the claim, i.e., evidence of a current disability, therefore, raising a reasonable possibility of substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110 (2010). New and material evidence having been submitted, reopening of the previously denied claim is appropriate. REASONS FOR REMAND Acquired Psychiatric Disorder The Veteran received a VA examination in October 2006 and the examiner noted a diagnosis of a mood disorder. She found that the condition was less likely as not related to treatments during military service but did not offer a rationale for her conclusions. A July 2012 VA examiner diagnosed depressive disorder and concluded that such started a few years ago and “lacks (sic) contents related to military service” and is therefore not related to service. That examiner also confirmed that the Veteran does not meet the criteria for a diagnosis of PTSD. The Board finds this examination inadequate as well as it did not address the PTSD diagnosis found in the Veteran’s treatment records. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence... is essential for a proper appellate decision.”). Therefore, this claim must be remanded for a new examination. Additionally, the Board finds that the medical evidence associated with the record is incomplete. The last VA treatment record in the file is from 2012, more than eight years ago. Accordingly, as more recent VA records are likely to contain pertinent information and because they are constructively of record, they must be obtained prior to adjudication of this claim. The matter is therefore REMANDED for the following action: 1. Obtain for the record complete clinical records of all VA evaluations and treatment the Veteran has received for his psychiatric disability (i.e., update to the present all records of VA evaluations and treatment from all VAMCs). 2. Thereafter, schedule the Veteran for a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims folder should be reviewed by the examiner. Based on review of the record (including this remand), and interview and examination of the Veteran, the examiner should provide opinions that respond to the following: (a) Identify by diagnosis each and every psychiatric disability the Veteran currently has (or has had at any time during the appeal period). (b) For each diagnosis identified other than PTSD, is it at least as likely as not that disorder manifested in or is otherwise related to the Veteran’s military service? (c) Does the Veteran at least as likely as not (a 50% or better probability) have a diagnosis of PTSD related to a corroborated stressor event in service? If PTSD is not diagnosed, explain why the Veteran does not meet the criteria for such diagnosis AND specifically reconcile that finding with the diagnosis of PTSD found in the Veteran’s VA treatment records. In answering the foregoing, the examiner should note that the Veteran is in receipt of a Purple Heart for his service in Vietnam and that a stressor has already been conceded. The examiner is also asked to consider the July 2011 VA treatment record that provides evidence that the Veteran’s symptoms of PTSD may be related to his alcohol intake. 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 complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. T. Matta Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, Associate Attorney 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.