Citation Nr: 21000864 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 17-01 344 DATE: January 6, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veterans served in the Navy from January 1981 to February 1985. The Veteran filed an original disability claim in November 2013 for service connection of post-traumatic stress disorder. After the claim was denied, the Veteran filed a timely notice of disagreement in September 2014. In July 2020, the Veteran offered testimony at a virtual hearing before the Board of Veteran Appeals (Board) and a transcript is of record. Entitlement to service connection for PTSD is remanded. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection for PTSD has unique evidentiary requirements; it generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). With regard to verifying the stressor event, the Veteran testified at the July 2020 hearing that his PTSD stressor event occurred when he was a member of a helicopter flight crew on July 14th, 1984. The Veteran was occupying a helicopter with Lieutenant PM. The conditions were dangerous because it was dark and the sea was rough. A mishap occurred during the landing of the helicopter on the deck of the frigate USS Reasoner. The Veteran described the incident in great detail and related that the situation created extreme danger for himself, Lieutenant PM and others. The Veteran described that one fear created by the incident was a fear of the helicopter falling overboard because of the difficulty in attempting to evacuate from a helicopter once it has fallen into the water. The Veteran testified that one after effect of the incident is that he is not comfortable being a passenger in an automobile and will only travel by car if he is the person driving the car. The stressor event is further verified by Lieutenant PM, who provided a statement that also offers great detail with regard to the incident and largely corroborates the details described by the Veteran, including the apprehension of great danger at the time of the incident. He also accessed and referenced flight logs to refresh his recollection. Lieutenant PM’s statement is of record. It is noted that Lieutenant PM subsequently was progressively promoted and achieved the rank of Rear Admiral later in his career. The Veteran testified to this information, there are flight records in the claims file, and also there is an email reflecting information regarding the Lieutenant’s career in the claims file. The Regional Office (RO) made efforts to verify the stressor event. On September 13, 2013, the RO issued a record to the file entitled “Formal Finding on a lack of information required to verify stressors in connection to the PTSD claim” The RO listed all of the efforts made to date and concluded that any further attempts to locate information would be futile. General information about the USS Reasoner is documented in a DPRIS Response dated September 2013, and the Veteran’s Military Personnel Record evaluation dated April 1, 1984 to October 2, 1983 reflects that the Veteran became damage control PQS qualified aboard the USS Reasoner. With regard to the Veteran’s subsequent in-service behavior after the stressor event, the Veteran testified at the July 2020 hearing: “When I got out of that flight, I didn’t want to fly no more. They said, man please you can’t shut us down we won’t be mission capable. You know it’s hard when you go through something like that you think that everything is OK until you have a close call and then you realize how much your life is in somebody else’s hands.” Changes in the Veteran after the stressor event are reflected in the Veteran’s STR’s. Prior to the stressor incident in July 1984, the Veteran’s job performance was rated superior and progressing towards advancement. (Evaluation July 1983 to March 1984). After the stressor incident, the Veteran’s reliability score decreased and he was not recommended for reenlistment. (Evaluation April 1984 to October 1984). When the Veteran was informed on 3 weeks’ notice that he was deploying, the Veteran said he did not want to go to sea and so did not want to carry out the extension of his enlistment. In a February 1985 statement, the Veteran conveyed that his decision to withdraw was due to several issues involving his wife. The Veteran does not mention the stressor event in this statement. The Commanding Officer (CO) responded that the Veteran did not make any of this information (about his wife) known until the detachment was mobilized and the Veteran refused help that was offered for the situation with his wife. Since she was also active duty in the Navy, the CO seemed dissatisfied with the Veteran citing to his wife as justification for not wanting to participate in the deployment. See statements in Personnel records February 1985. The Veteran testified that he suffers from symptoms of a current disability. Medical records in the file reflect that the Veteran is receiving treatment. Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The requirements to secure a VA examination are a low bar, and this evidence triggers VA’s duty to assist. Under the duty to assist, a medical examination or medical opinion is considered necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the claimant suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with an established event, injury or disease in service or with another service-connected disability. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159 (c)(4). It is unclear from the record whether the Veteran has a currently diagnosed PTSD under the DSM-V. In this regard, the Board observe an assessment of PTSD was made in an October 2014 mental health note. However, more recent treatment notes dated in December 2019 note that PTSD screening was negative. Therefore, a remand is necessary for the VA to fulfill its duty to assist and afford the Veteran an examination for his PTSD claim to ascertain whether he has met the appropriate DSM criteria for a diagnosis of PTSD at any time during the course of the appeal and, if so, whether the PTSD is related to an inservice stressor. The matters are REMANDED for the following action: 1. Afford the Veteran a VA mental disorders examination with a Psychiatrist or Psychologist to determine the diagnosis, nature and etiology of any psychiatric disorder to include PTSD. The examiner must review this remand and the record and should note that the review took place in the report. An interview of the Veteran regarding his psychiatric history, a psychiatric examination, and any tests and studies required should be performed. The VA examiner should specifically note and discuss the Veteran’s claimed stressor. A complete rationale should be provided for all opinions and conclusions. The examiner is asked to offer opinions as follows: a) Provide a diagnosis for any acquired psychiatric disorder that is currently manifested or that has been manifested at any time since January 2013. b) For any diagnosed psychiatric Disorder to include PTSD, the examiner should provide an opinion as to whether the disability is at least as likely as not (50 percent or greater probability), incurred in service or otherwise related thereto, to include PTSD resulting from the corroborated in-service stressor incident described by the Veteran? c) If PTSD is diagnosed, the examiner should also specifically discuss whether the criteria for diagnosing PTSD per the DSM-V are met, and, if so, whether the diagnosis is related to the stressor event mentioned by the Veteran. The examiner is requested to comment on the Veteran’s behavioral changes/apparent decrease in job performance evaluations in 1984 and 1985 following the alleged in-service stressor event as evidenced by the Veteran’s in-service evaluations and statements contained in the claims file. The examiner is advised that the Veteran is competent to report symptoms and that his reports must be considered in formulating the requested opinion. If the Veteran’s reports are discounted, the examiner should provide a reason for doing so. The examiner is also advised that the absence of evidence in the STRs is an insufficient basis, by itself, for a negative opinion. A complete rationale should be given for all opinions and conclusions expressed, and a discussion of the facts and medical principles involved must be provided. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.