Citation Nr: 21003012 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 10-45 033 DATE: January 19, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1968 to May 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a February 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2010, the Veteran testified at a hearing before a Decision Review Officer. A transcript of the hearing has been associated with the Veteran’s claims file. In July 2017 and April 2019, the Board remanded the Veteran’s claim for additional development. The case is once again before the Board. Entitlement to service connection for an acquired psychiatric disorder is remanded. In December 2019, VA scheduled the Veteran for a psychiatric examination. There, the examiner diagnosed the Veteran with an unspecified anxiety disorder but opined that it was related to the Veteran’s family situation, not service. In reaching that conclusion, the examiner relied on two premises: (1) the Veteran’s pre-military, military, and post-military service records show no complaint of or treatment for a mental disorder, and (2) the Veteran’s first mental health complaint was in 2017, 48 years after separation. Unfortunately, the first requires further medical explanation, and the second is not accurate. Starting with the first premise, it is technically true that the Veteran’s service records show no complaint of or treatment for a mental disorder. That said, the Veteran testified during a December 2010 hearing before a decision review officer that he experienced shortness of breath because of his anxiety during service. Indeed, the Veteran’s service records do show that. Specifically, in November 1968, the Veteran presented with difficulty breathing and was referred to the emergency room. There, he says the military doctor who attended him told him there was nothing physically wrong with him and that his difficulty breathing could be due to his stress. To help guide the examiner on remand, the Board also notes that the Veteran reported labored aspiration on a September 1965 medical history but denied shortness of breath on the following three. Moving on to the second premise, the Veteran also testified during his hearing that he suffered a similar episode while working for the Puerto Rico Police in the late 1970s. In support of his claim, he submitted evidence showing that he was diagnosed with an anxiety reaction and forced to separate from the police because of his emotional disorder. He also submitted a June 2009 private medical opinion from Dr. Ortiz, who noted that the Veteran presented with a chronic anxiety disorder. Either way, the Veteran’s first mental health complaint occurred well before 2017. Because the examiner’s medical opinion is based on a false premise, remand is required for an addendum opinion. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Finally, as the case is being remanded for additional development, any outstanding VA treatment records should be associated with the claims file. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (per curiam). The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Arrange for an appropriate healthcare provider to review the Veteran’s claims file and provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any acquired psychiatric disorder including an unspecified anxiety disorder had its clinical onset during service or is due to an event or incident of the Veteran’s period of active service. The examiner must address (1) the Veteran’s contention that his mental disorder manifested with shortness of breath during service, and (2) the Dr. Ortiz’s June 2009 Private Medical Opinion, finding the Veteran’s mental disorder related to his service. In rendering an opinion, the examiner’s attention is drawn to (i) the Veteran’s November 1968 service treatment record noting difficulty breathing, and (ii) the May and December 1978 Medical Certificate from the Puerto Rico Police showing a diagnosis of anxiety reaction. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran’s pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Canedy, 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.