Citation Nr: 20036331 Decision Date: 05/27/20 Archive Date: 05/27/20 DOCKET NO. 17-28 517A DATE: May 27, 2020 REMANDED Entitlement to service connection for high blood pressure, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for frequent nose bleeds, to include as due to an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1983 to July 1991. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran provided sworn testimony before the undersigned Veterans Law Judge (VLJ) at a Board hearing. A copy of the hearing transcript has been associated with the electronic claims file. The Board acknowledges that the Veteran submitted a request for a copy of his claims file after the hearing, and that request has been acknowledged by VA and remains pending. Ordinarily the Board would defer deciding his appeal until that request had been fulfilled. However, it is clear from his testimony that a remand is warranted, as discussed below, so delaying issuance of this remand to fulfill his request for a copy of his claims file would only add months to resolution of his appeal and serve no purpose. Therefore, the Board will proceed. Although the Board regrets the additional delay, a remand is necessary to ensure due process and proper development regarding the Veteran’s claims. The Veteran asserts that he suffers from a number of symptoms due to his Gulf War service, to include hypertension, chronic fatigue syndrome (CFS) and chronic nosebleeds. The Veteran was provided with a VA Gulf War medical examination in February 2012. The examiner’s opinion read as follows: “there are no undiagnosed illnesses. There is no objective evidence on history or physical exam of chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome. There are no conditions presumptive of Gulf War Environmental Hazards.” The examination report included discussion of the Veteran’s claimed hypertension and CFS but provided negative opinions; and noted there was no diagnosis for CFS or nose bleeds. However, a remand is required to obtain private medical records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). This includes making reasonable efforts to obtain relevant private medical records. See 38 C.F.R. § 3.159(c)(1). At the 2020 hearing, the Veteran testified that he was seen by a private doctor beginning in 1992 where he was first told he had elevated blood pressure and diagnosed with hypertension; that he reported his fatigue right after separation from service; and he and his wife testified as to his chronic nose bleeds and stated his private doctor had diagnosed him. However, the Veteran’s file only has medical records from his private doctor between 1995 through 2014. During the hearing, the Veteran also stated that he was planning to discuss the claimed conditions with his private doctor, indicating there may now be relevant private treatment records. Further, the Veteran mentioned he had been in a car accident and received medical treatment after the accident while in service; his VA medical records indicated he had private medical treatment regarding his sleep apnea which may be relevant for his claimed fatigue; and he had also reported in June 2001 that he had received medical treatment by nurses at his work. As such, a remand is necessary to undertake reasonable efforts to obtain the records beginning in 1992 from Dr. Murthy; medical records from his employment in the 1990’s and 2000’s; any medical records from his car accident during service; and any recent private medical records. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records from April 2017 to present and associate them with the claims file. 2. Request the Veteran to submit or complete VA Form 21-4142 for any relevant updated and/or outstanding private treatment records; specifically: • any medical records from Dr. Murthy between 1992 and 1995, and any records for treatment from that doctor since 2014; • medical records for his sleep apnea; • medical records from the car accident in service; • employment medical records in the 1990s-2000’s; and • any other relevant private medical records. Thereafter, request the identified and authorized records. All information obtained must be made part of the file and all attempts to secure this evidence must be documented in the claims file; and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After completing the above actions, consider whether further examinations or opinions are warranted based on any additional records received. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.Hoy, 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.