Citation Nr: 20032889 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 19-07 410 DATE: May 12, 2020 REMANDED Entitlement to service-connection for residuals of a perineal injury is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1978 to October 1982. The issue comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service-connection for residuals of a perineal injury is remanded. The Veteran contends that he has a perineal injury that was incurred in service. Specifically, a July 2015 statement, he reported sustaining a fall during service, injuring the groin and buttock area, which hospitalized him for two weeks. He also avers that said injury has caused him infertility, since he has been unable to have children, and periodic excruciating pain in the area off and on, that forces him to lay down for a while. Thus, as the Veteran has described having pain and functional impairment, he has a current disability. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018) (holding that “pain in the absence of a presently-diagnosed condition can cause functional impairment”). The Veteran’s service treatment records (STRs) show a May 1981 entry from the Department of Surgery/General Hospital, noting that the Veteran was hospitalized for 14 days for perineal injury/laceration. The injury did not involve damage to any arteries or nerves. The STRs also show various entries of complaints of testicle pain. The Veteran was scheduled for VA examinations in August 2015 and December 2018. The examinations were canceled for the Veteran’s failure to report. Regarding the August 2015 canceled examination, the Veteran provided a March 2017 statement that he did not recall receiving information instructing him to attend the examination on August 03, 2015, and his “representative was able to find a medical record showing [that he] was treated on that date by a VA mental health provider. During that same time, [he] was [also] having housing problems and had been to a shelter.” Regarding the December 2018 canceled examination, the records show that the Veteran was unrepresented at the time. Further, a Report of General Information (RGI) dated in January 2019 noting the Veteran’s current address of file (a Miami, Florida address) was incorrect, “and the Veteran could not verify the address of record.” A Riverview, Florida address was added to the Veteran’s claims file. As the Board finds good cause exists for the Veteran’s failure to report for his scheduled VA examinations, a new examination is warranted to determine the possible etiology of the Veteran’s perineal injury disability. The Board takes this opportunity to alert the Veteran that should he miss any future scheduled VA examination without good cause, it will have adverse consequences for his claim since the claim will be rated based on the evidence of record. 38 C.F.R. §§ 3.655 (a)-(b). VA’s duty to assist a veteran is not a one-way street, and the Veteran must cooperate to the full extent in the development of his claim. Wood v. Derwinski, 1 Vet. App. 406 (1991). The Board also notes that the Veteran in his September 2015 notice of disagreement (NOD) requested an informal telephone conference. The record is absent such a conference took place. Moreover, the Veteran’s representative in his argument of April 2020 suggests a “rescheduled … examination after confirming positive contact information. Perhaps a telephone call is in order.” Accordingly, the matter is REMANDED for the following action: 1. Provide the Veteran and his representative with the requested informal telephone conference. 2. Provide the Veteran’s claims file to a suitable clinician so that an opinion may be provided assessing the nature and etiology of the residuals of his perineal injury. The entire claims file and a copy of this remand must be made available to the examiner for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. If an examination is scheduled, the Veteran is advised that failure to report for a scheduled VA examination without good cause may have adverse consequences for his disability claim. Although an independent review of the claims file is required, the Board draws the clinician’s attention to the following: a. STR entry dated in May 1981, noting 14-day hospitalization for perineal injury/laceration; no nerve or artery involvement. b. April 1982 separation wherein normal anus and rectum. c. November 1980, February 1982, and September 1982 complaints of testicular pain absent a history of trauma. d. July 2015 statement, wherein he reported an in-service fall, injuring the groin and buttock area and hospitalized him for two weeks. He also avers that said injury has caused him infertility, since he has been unable to have children, and periodic excruciating pain in the area off and on, that forces him to lay down for a while. The clinician should provide an opinion as to whether any diagnosed residuals of perineal injury is at least as likely as not (a 50 percent or degree of probability) had its onset in service or is otherwise related to service. The clinician is advised that, even if there is no diagnosable pathology of any residuals of a perineal injury, complaints of pain plus functional impairment is akin to a diagnosed physical disability. The clinician must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such a conclusion. 3. Then, readjudicate the claim. If any decision is adverse to the Veteran, issue a supplemental statement of the case, and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Stevens, 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.