Citation Nr: 21001647 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 14-20 652A DATE: January 11, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include an anxiety disorder and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1981 to September 1987. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). It was previously before the Board in November 2019, where it was remanded for additional development. The Board notes that the Veteran received an October 2020 letter from VA indicating that he could request a virtual tele-hearing instead of waiting for a travel board hearing. Upon further review, the Veteran did not have a pending hearing request and the letter was sent in error as the Veteran already provided testimony in a hearing with the undersigned Veterans Law Judge in February 2019. Moreover, the Veteran stated in a November 2020 correspondence that he did not wish for an additional hearing. While the Board regrets further delay, the Veteran’s claim must again be remanded for additional development. First, the Board instructed the RO in its previous remand directives to obtain any remaining VA treatment records, including from the Hines VA Medical Center (VAMC) in the Chicago, Illinois area beginning in 1990, as the Veteran reported treatment there in his hearing testimony. If it was determined that records did not exist or were unavailable, the Veteran was to be properly notified of their unavailability. Review of the record does not reflect that any attempt was made to obtain any missing VAMC records. In addition, in the Board’s previous remand it was noted that VA was in the process of scheduling the Veteran for a VA examination to address a separate service connection claim for anxiety and, as such, the claim was deferred and remanded pending completion of this examination. The RO was to then adjudicate the Veteran’s anxiety claim as part of his claim for an acquired psychiatric disorder. See Clemmons v. Shinseki, 23 Vet. App. 1, 6 (2009). The record since the Board’s previous remand reflects that the VA examination was afforded to the Veteran in December 2019, where an anxiety disorder was diagnosed, rather than PTSD. However, while the examiner provided an etiological opinion that the Veteran’s anxiety disorder was not related to his service-connected hearing loss on a secondary basis, no opinion was provided as to whether the disability was related to his military service on a direct basis. See 38 C.F.R. §§ 3.303, 3.310. Further, the Veteran submitted the July 2020 opinion of a private psychologist diagnosing him with PTSD and attributing it to his military service, although the report does not make clear what stressor/traumatic event caused the PTSD. There is some reference to the Veteran convincing a friend to join the military and the friend being injured during service and later committing suicide, although it is unclear if this was the basis for the PTSD diagnosis or even when the Veteran convinced his friend to join the military (before or after his own entry into the military). Notably, that event was described in the “Sentient Event (Other than Stressors)” portion of the report. As such, an additional VA examination should be obtained that addresses any and all acquired psychiatric disorders. The matter is therefore REMANDED for the following actions: 1. Ask the Veteran to identify any outstanding treatment records relevant to his acquired psychiatric disorder claim. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. §3.159(c)-(e)), to include notifying the Veteran of their unavailability. 2. Relevant treatment records from the Brown and Hines VA Medical Centers, beginning in 1990, should be obtained. All attempts to obtain these records should be clearly documented in the claims file for the Board’s review. If any records are determined to be unavailable, the Veteran should be notified of the unavailability of the records. 3. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a current acquired psychiatric disorder onset during service or is otherwise related to an in-service injury, event, or disease, to include the Veteran’s reported stressors. In so doing, the examiner is also asked to: (a) Identify all appropriate psychiatric diagnoses. The examiner is asked to comment on the July 2020 independent medical opinion diagnosing PTSD. (b) If PTSD or a trauma- or stressor-related disorder is diagnosed, identify the traumatic event(s) forming the basis for the diagnosis. The Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history he has provided, the examiner should provide a fully reasoned explanation. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, 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.