Citation Nr: 20060109 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 15-22 130 DATE: September 14, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1965 to November 1972. He served honorably in the U.S. Air Force, including service in Japan during the Vietnam era. The Board thanks the Veteran for his service to our country. The issue of service connection for an acquired psychiatric disorder was previously before the Board in February 2019, when the Board denied entitlement. The Veteran appealed the Board’s decision to the U.S. Court of Appeals for Veterans Claims (Court). In an April 2020 Order, granting an April 2020 Joint Motion for Remand (Joint Motion), the Court vacated and remanded the February 2019 Board decision consistent with the terms of the Joint Motion. The case has now returned to the Board for further appellate review and readjudication consistent with the terms of the Joint Motion. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. A remand is warranted to afford the Veteran an examination. The Veteran reported injuring his knee when he was walking down a trail in the Republic of Vietnam and waking up in Okinawa with an injured leg; reported exchanging fire when traveling between bases in Vietnam, witnessing injuries, and coming into contact with a child with a satchel charge; and in a November 2014 statement in support of claim for PTSD stated that he was in the hospital and told that he had been injured in a training exercise and had great pain in his left knee. The April 2020 Joint Motion stated that the Board did not address whether July and August 1968 service treatment records noting left knee injuries are sufficient corroboration of an in service stressor related to the Veteran’s PTSD diagnosis. It also noted a June 2014 VA psychology note in which the Veteran endorsed having dreams and negative emotions associated with his leg injury as well as a July 2014 note in which the treating psychologist concluded that the Veteran’s symptoms meet the criteria for PTSD and are likely the result of the traumas to which he was exposed while in the military, including his leg injury. As there is an indication that the Veteran’s disorder may be related to service, a VA examination is warranted. A remand is additionally warranted as there may be service treatment records which have not been associated with the file. In an August 2002 statement in support of a knee injury claim, the Veteran stated that he was in the hospital for a long time after injuring his knee and in an August 2013 psychology note he reported being injured checking the perimeter and waking up in traction after several days of unconsciousness with a hand and left knee injury. A September 1968 clinical record cover sheet includes admission notes and indicates that the Veteran had spent 44 days in the hospital or infirmary. However, a review of the treatment records found no in-patient treatment records from that time. Finally, a remand is warranted for further evidentiary development. The Veteran, a security policeman in service, stated that he was one of 150 troubleshooters with a quick reaction force who, for logistical purposes, had temporary days-long deployments to Vietnam; he stated that he had gone under orders twice. January and April 1969 performance reviews noted that the Veteran had performed security duties in support of priority resources in direct support of military operations in southeast Asia and a June 1971 uniform airman record affirmed hazard/special duty status, though it is unclear what period of time the status covered. However, the record does not reflect development with respect to stressor corroboration or verification of service in the Republic of Vietnam. The Board emphasizes that it is not determining whether or not the Veteran’s statements regarding combat service in Vietnam are credible at this time, as the additional development set forth in the directives below could impact that determination. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disabilities on appeal. Please ask the Veteran to provide the releases necessary for VA to secure private treatment records. 2. Please attempt to obtain the Veteran’s in patient treatment records from U.S. Army Hospital Ryukyu Islands from August 1968 to September 1968 and document all requests for information as well as all responses in the claims file. For more details and exact dates of admission and discharge see STR – Medical file associated with the record on September 7, 2002: September 20, 1968 clinical record cover sheet and October 10, 1968 clinical record narrative summary (pages 49 and 51 of 83, respectively). 3. Please request and document responses regarding verification or corroboration of the Veteran’s claimed temporary service in or orders to the Republic of Vietnam from the JSRRC in July or August 1968 when he was with the 824 Security Police Squadron, Kadena Air Base, Okinawa. If the Veteran’s temporary service in or orders to the Republic of Vietnam cannot be verified, the file must be so annotated. 4. After the development in paragraphs 1-3 is complete, please refer the claim ot a clinician for an opinion as to the nature and etiology of an acquired psychiatric disorder. The Veteran’s claims-file must be made available to and reviewed by the clinician. The clinician is requested to opine as to the following: (a.) Please identify by diagnosis all acquired psychiatric disorders current during the period on appeal, including PTSD. (b.) For each disorder identified, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) related to service. (c.) With respect to the Veteran’s PTSD, please opine as to whether the Veteran’s left knee injury, incurred in a karate exhibition in Okinawa, and its residuals is adequate, standing alone, to support a diagnosis of PTSD. The clinician is advised that the Board has not accepted the veteran's report of combat service in Vietnam at this time. (d.) If there are any other stressors confirmed as a result of requested development, as to each, please opine whether each stressor is adequate to support a diagnosis of PTSD. ONLY IF the clinician determines that an examination is necessary for the addendum opinion, the Veteran should be scheduled for an appropriate VA examination to determine the nature and etiology of the disorder. The clinician must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician 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. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Vashaw, 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.