Citation Nr: 21002203 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 18-44 515 DATE: January 13, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1962 to May 1966. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for PTSD. In May 2015, VA received the Veteran’s Notice of Disagreement (NOD). A Statement of the Case (SOC) was issued in August 2016. A timely substantive appeal was received in August 2016. In an October 2018 decision, the Board remanded the matter for additional evidentiary development. A Supplemental Statement of the Case (SSOC) was issued in August 2020. Entitlement to service connection for an acquired psychiatric disability, to include PTSD. The Veteran claims that he has PTSD as a result of his experiences serving aboard the U.S.S. Kearsarge in the waters offshore the Republic of Vietnam. See e.g., June 2014 Statement in Support of Claim for Service Connection for PTSD; August 2016 VA Form 9; and November 2016 correspondence. Specifically, he reports that his duties included manning a 5-inch cannon and he was “always in fear of hostile activity as he was always seeking enemy PT boats with the ability to shoot torpedoes at them.” August 2016 VA Form 9. The Veteran underwent a VA examination in June 2014 at which time the examiner opined that the Veteran did not meet the diagnostic criteria for PTSD. Rather, the examiner diagnosed unspecified schizophrenia spectrum and other psychotic disorder, but failed to provide an etiological opinion for the diagnosed disabilities. In its October 2018 remand, the Board noted that the record on appeal reflected that since the June 2014 VA examination, the Veteran had been diagnosed as having PTSD and anxiety, although no etiological opinions had been provided. In addition, the Veteran had provided private medical opinions dated in November 2016 and December 2016 which noted that he met the TSI (Trauma Symptom Inventory) criteria for PTSD. However, these diagnoses were insufficient to meet the legal criteria for an award of service connection for PTSD. See 38 C.F.R. § 3.304(f) (requiring medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125). In light of the evidence of record, the Board remanded the matter to obtain a new medical examination and opinion. The Veteran was afforded another VA examination in September 2019. Unfortunately, the examination is inadequate in multiple respects. The examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD solely because the stressor reported by the Veteran at the examination – “operating in the fog and working with old equipment” – was inadequate to support a diagnosis of PTSD. The examiner, however, failed to address the stressors previously reported by the Veteran, to include the stressors related to his fear of hostile military activity. In addition, the examiner diagnosed the Veteran as having schizotypal personality disorder, unspecified anxiety disorder, alcohol use disorder in sustained remission, and unspecified amphetamine or other stimulant-related disorder. The examiner, however, offered no etiological opinions with regard to the Veteran’s other diagnoses, to include unspecified anxiety disorder, despite remand instructions to the contrary. Compliance with remand directives by the originating agency is not optional or discretionary. The Board errs as a matter of law when it fails to ensure remand compliance. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Schedule the Veteran for a medical examination to determine the nature and etiology of his current psychiatric disability. Access to the Veteran’s electronic claims folder must be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the record, the examiner should identify all psychiatric disabilities present since March 2014, to include any PTSD, unspecified schizophrenia spectrum and other psychotic disorder, anxiety disorder, mood disorder, and neurocognitive disorder. If the examiner determines that any prior psychiatric diagnosis was in error or has since resolved, an explanation should be provided. With respect to each identified psychiatric disability, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the psychiatric disability had its onset during service or is otherwise related to service. (Continued on the next page)   If PTSD is diagnosed, the clinician should specify the stressor(s) upon which the diagnosis was based, to include whether or not the stressor is related to the Veteran’s fear of hostile military or terrorist activity. A rationale for the opinions must be provided. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.D. Hobbs, 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.