Citation Nr: 21001904 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 18-13 252 DATE: January 12, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is granted. FINDING OF FACT The Veteran has a current diagnoses of PTSD and MDD; his current PTSD and MDD symptoms are proximately due to an in-service stressor; and there is credible supporting evidence that the claimed in-service stressor occurred. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD and MDD, are met. 38 U.S.C. §§ 1110, 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has verified active duty service in the United States Army from June 7, 1956, to July 19, 1957. See January 2015 Certification of Military Service; July 1957 United States Army Separation of Personnel memorandum (indicating a discharge date of July 19, 1957). The Veteran’s daughter asserted at the hearing that he served from 1953 to 1957. His service personnel and medical records, to include his DD Form 214, were lost in the July 1973 National Archives fire; thus the entirety of his service cannot be definitely verified. This matter comes before the Board of Veterans’ Appeals (Board) from an October 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a virtual hearing in August 2020. The Veteran relates his PTSD to combat experiences in Korea. See August 2020 Hearing Transcript at 5; March 2016 VA Form 21-0871, Statement in Support of Claim for Service Connection for PTSD. 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. § 1110, 1131; 38 C.F.R. § 3.303. Service connection for PTSD requires (1) medical evidence diagnosing PTSD; (2) a link, established by medical evidence, between a Veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). If a stressor claimed by the Veteran is related to his fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). With respect to element one of service connection, the presence of a current disability, the medical evidence of record indicates a current DSM-5 diagnosis of chronic PTSD. See March 2020 VA psychiatry note; June 2015 VA mental health note; May 2015 VA mental health note. Additional medical evidence of record indicates a diagnosis of MDD related to combat in Korea. See March 2020 VA psychiatry note; June 2015 VA treatment note; May 2015 VA mental health note. Thus, competent and credible medical evidence of record establishes that the Veteran has current diagnoses of acquired psychiatric disabilities, to include PTSD and MDD, and element one of service connection is, therefore, met. With respect to element two of service connection, a link between the Veteran’s diagnosed disability and the in-service stressor, the record contains a July 2020 letter authored by Dr. R.C., a VA psychiatrist who has been treating the Veteran for psychiatric issues. Dr. R.C.’s letter confirms the Veteran’s diagnosis of chronic PTSD and relates his PTSD to service. Specifically, Dr. R.C. writes that the Veteran’s current PTSD is the result of experiencing “gruesome war battles” in Korea. In addition, numerous VA treatment notes relate his PTSD and MDD to combat service in Korea. See, e.g., March 2020 VA psychiatry note (listing diagnosis of PTSD “following military combat”); February 2019 inpatient admission note (stating impression of “PTSD from Korean combat”); May 2015 VA mental health note (identifying PTSD and severe depression “related to his combat in Korea”). This medical evidence supporting a link between the Veteran’s PTSD and MDD and his combat experience is highly probative in light of the fact that it was provided by doctors who have treated the Veteran and are, therefore, closely familiar with the etiology of the Veteran’s condition and the claimed in-service stressor. Furthermore, there are no negative opinions of record. Thus, competent, credible, and probative medical evidence of record connects the Veteran’s PTSD and MDD to his active duty service, and element two of service connection is met. With respect to the final element of service connection, credible evidence supporting that the claimed in-service stressor occurred, the Veteran has described stressors related to his service in Korea. Specifically, the Veteran described an incident in service when his unit came under enemy fire from villagers during a patrol. See August 2020 Hearing transcript at 5; March 2016 VA Form 21-0871 Statement in Support of Claim for Service Connection for PTSD; April-September 2015 social work notes; see also April 2019 VA psychiatry admission evaluation note (describing flashbacks related to this incident); February 2016 VA social work note (stating the Veteran reported being in combat in Korea and “feeling as though his life was at risk”). The Veteran asserts that during this incident he shot and killed one villager, he was ordered to throw grenades into village huts with children inside, and fellow soldiers on either side of him were shot and killed by the enemy. See id. Because the Veteran’s military service records were lost in the July 1973 National Archives fire, there are no contemporaneous records documenting the occurrence of the claimed in-service stressor. See VA 3101 print (indicating the documents needed to respond to a request for service treatment and personnel records were “fire-related,” suggesting they were never recovered from the fire); September 2016 DPRIS response (indicating a lack of documentary evidence to confirm the Veteran’s unit was in Korea). Despite the lack of documented evidence, there is competent, credible, and probative lay evidence of record that supports that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f)(3). Here, the Board notes that the Veteran’s claimed in-service stressor is related to “fear of hostile military or terrorist activity.” Id. In this regard, the Veteran’s stressor occurred when his patrol unit came under hostile fire from villagers and some of his fellow servicemembers were shot and killed. In a February 2016 VA social work note, the Veteran reported fearing for his life during combat in Korea. In his July 2020 letter, Dr. R.C. related the Veteran’s PTSD to the battles he experienced in Korea, thus confirming that the claimed in-service stressor is “adequate to support a diagnosis of [PTSD] and that the veteran’s symptoms are related to the claimed stressor.” Id. Furthermore, VA clinicians are skilled in identifying war trauma; thus, Dr. R.C.’s opinion linking the Veteran’s PTSD to the claimed stressors supports the Veteran’s assertion that the stressors occurred. In addition, the Veteran has consistently provided the same account of the in-service stressor and there are no service records contradicting the Veteran’s claim. See August 2020 Hearing transcript at 5; April 2019 VA psychiatry admission evaluation note; March 2016 VA Form 21-0871 Statement in Support of Claim for Service Connection for PTSD; February 2016 VA social work note; April-September 2015 social work notes. The Board notes that the Veteran’s treatment records support a finding that Dr. R.C. is a VA psychiatrist. See July 2020 letter (Dr. R.C. stating he has been providing psychiatric treatment to the Veteran); March 2020 VA psychiatric progress note (authored by Dr. R.C.); October 2019 VA mental health patient record (indicating the Veteran’s principal mental health provider is Dr. R.C.). Thus, while the treatment records do not explicitly identify Dr. R.C. as a psychiatrist, they establish that he is a VA doctor working in psychiatry and providing psychiatric treatment, which the Board finds sufficient to satisfy the requirement of 38 C.F.R. § 3.304(f)(3). While Dr. R.C. did not explicitly state that the Veteran’s fear of hostile military action was adequate to support his diagnosis of PTSD, a competent PTSD diagnosis is presumed to include the adequacy of the symptomatology and the sufficiency of the stressor. See Cohen v. Brown, 10 Vet. App. 128, 138 (1997). In view of the Veteran’s consistent and credible reports regarding the in-service stressor, as well as Dr. R.C.’s confirmation of the Veteran’s PTSD diagnosis based on the same, the Board finds that evidence of record demonstrates that Dr. R.C., a VA psychiatrist, confirmed that the Veteran’s PTSD is related to the Veteran’s fear of hostile military or terrorist activity. Although there are no service records to corroborate the Veteran’s assertions, the Board finds that the benefit-of-the-doubt doctrine is for application, and the Board resolves all doubt in the Veteran’s favor. After resolving all doubt in the Veteran’s favor, the Board finds that the Veteran’s credible lay testimony has adequately established the occurrence of the in-service stressor, that the claimed stressor is consistent with the circumstances of the Veteran’s service, and that there is not clear and convincing evidence that the stressor did not occur. See 38 C.F.R. § 3.304(f)(3).   Thus, for reasons and bases outlined above, the final element, and all elements of service connection for PTSD and MDD, are met, and the benefit sought on appeal is granted. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. deBruyn, 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.