Citation Nr: 20032718 Decision Date: 05/11/20 Archive Date: 05/11/20 DOCKET NO. 18-42 749 DATE: May 11, 2020 REMANDED Entitlement to service connection for hernia hiatal is remanded. Entitlement to service connection for an acquired psychiatric disorder (claimed as a sleeping disorder), to include posttraumatic stress disorder (PTSD), to include as secondary to an in-service personal assault, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to May 1969. This claim comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. The Veteran requested a hearing before the Board, but withdrew his request for a hearing in February 2020; the Board will proceed to review the case based on the evidence of record. See 38 C.F.R. § 20.704(e). 1. Entitlement to service connection for hernia hiatal is remanded. The Veteran contends that his current hernia hiatal condition is due to his active service, specifically to being punched repeatedly in the stomach during basic training. The Veteran’s post-service VA treatment records show that the Veteran has been seeking treatment for hernia conditions, including hiatal hernia and ventral hernia, since 1995. The Veteran has not been afforded a VA examination for this condition. Accordingly, this claim must be remanded so that he can be afforded a VA examination on the nature and etiology of his hernia hiatal condition. 2. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran’s claim was originally filed as one of entitlement to service connection for sleeping disorder. In a statement in support of the claim submitted along with the VA 21-526EZ, the Veteran explained that he was assaulted by his staff sergeant numerous times throughout basic training. He further explained that he had trouble sleeping during basic training after these assaults and went on to say that he still has trouble sleeping through the night. In an informal conference call with VA in June 2018, the Veteran’s representative advised that “while the Veteran claimed, ‘sleeping disorder’ he meant to claim a mental disorder, trouble sleeping due to an assault that allegedly occurred during the Veteran’s military service.” See VA 27-0820 Report of General Information. In light of this information, VA sent the Veteran a development letter for VA 27-0781 statement in support of claim for service connection for PTSD and VA 27-0781a statement in support of claim for service connection for PTSD secondary to personal assault in June 2018. The Veteran submitted a completed VA 27-0781a form in February 2020. Additionally, in February 2020, VA received a letter from the Veteran’s representative clarifying the issues on appeal. In the letter, the Veteran’s representative advised that the Veteran’s claim is not for sleeping disorder, but rather an acquired psychiatric disorder, to include as secondary to personal assault, with trouble sleeping to be included as a symptom. Considering the Veteran’s contentions and the evidence of record, the Board has recategorized the Veteran’s claim for sleeping disorder as a claim for an acquired psychiatric disorder, to include PTSD, to include as secondary to an in-service personal assault in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran asserts that he suffers from a current psychiatric disorder, to include PTSD, as a result of service. The Veteran claims to have been repeatedly punched in the stomach during basic training by a staff sergeant, but this potential stressor has not been corroborated. See Correspondence, received by VA in March 2016, and VA 27-0781a, received by VA in February 2020. The Veteran has not been afforded a VA examination for this condition. Accordingly, this claim must be remanded so that he can be afforded a VA examination on the nature and etiology of his psychiatric condition. The matters are REMANDED for the following action: 1. Make efforts to obtain all outstanding medical records in accordance with duties set forth in 38 C.F.R. § 3.159(c). 2. Perform any additional stressor development warranted based on the Veteran’s reports. Consideration should be given to the Veteran’s correspondence, received by VA in March 2016, and the statement in support of claim for PTSD (VA 27-0781a), received by VA in February 2020. 3. After all development has been undertaken, schedule the Veteran for a VA examination, with a psychiatrist or psychologist, to determine the nature and etiology of all psychiatric disorders, to include PTSD, present during the period on appeal. The entire claims file, including a copy of this remand, must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a full history and/or description of his active service: (a.) Identify all psychiatric disorders present during the pendency of the appeal. (b.) For each non-PTSD psychiatric disorder diagnosed, provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each disorder had its onset in, or is otherwise related to, active service. A complete rationale must be provided for all opinions. (c.) If stressor verification is accomplished and a diagnosis of PTSD is deemed appropriate, the examiner should also opine as to whether the identified stressor is adequate to support the diagnosis of PTSD. (d.) If stressor verification is not accomplished and a diagnosis of PTSD is deemed appropriate, the examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or higher) that the Veteran exhibited symptoms and behaviors consistent with behavioral changes expected to follow from the claimed personal assault, and if so, whether PTSD is related to the alleged incident. A complete rationale must be provided for all opinions. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity for an examination. If a VA examination proves not feasible for any reason, the claims file should still be reviewed by an appropriate professional for the purpose of providing the requested opinions. 4. Schedule the Veteran for VA medical examination to the nature and etiology of his hernia hiatal. The entire claims file, to include a complete copy of this remand, must be reviewed by the examiner. All indicated tests should be performed, and all findings should be reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that hernia hiatal is related to active service. A complete rationale must be provided for all opinions. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity for an examination. If a VA examination proves not feasible for any reason, the claims file should still be reviewed by an appropriate professional for the purpose of providing the requested opinions. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fairlie, 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.