Citation Nr: 21003130 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 17-32 602 DATE: January 19, 2021 REMANDED Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from May 1968 to February 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in February 2020. A transcript of the hearing has been associated with the claims file. 1. Entitlement to service connection for PTSD is remanded. The Board finds that the claim must be remanded for the RO to obtain outstanding VA treatment records and to assist the Veteran in obtaining private treatment records relating to his PTSD. The Board sincerely regrets the additional delay caused by this remand but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claim. In February 2020, the Veteran testified that he saw a mental health provider at the John Dingell VAMC “not too long ago.” See Hearing Transcript, p. 20. However, the most recent VA treatment records in the claims file were uploaded in April 2017. As such, a remand is necessary to ensure that all relevant VA treatment records have been obtained and associated with the electronic claims file. 38 U.S.C. § 5103A(c); 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). The Veteran also testified that he receives treatment from Dr. A.B., a psychiatrist, and Dr. A.M., an internal medicine physician. See Hearing Transcript, p. 21. The most recent records from both physicians that have been associated with the claims file are dated March 2017. See Medical Treatment Record – Non-Government Facility, pp. 1-2. The Board finds that in light of the Veteran’s testimony almost three years after the dates of the most recent records, efforts should be made to obtain all private treatment records from both Dr. A.B. and Dr. A.M. 38 U.S.C. § 5103A(b); 38 C.F.R. § 3.159(c)(1). The Board further notes that Dr. A.B. has treated the Veteran for PTSD, severe anxiety, and bipolar disease. See Medical Treatment Record – Non-Government Facility, p. 1. Additionally, the Veteran has testified that his “violent behavior came out” while serving in the Philippines. See Hearing Transcript, p. 23. He also testified that he experienced his first encounter with drugs while serving. Id. He further stated that during bootcamp, he suffered an eye injury during an exercise potentially relating to gas chambers. Id. at 18-19. In a Statement in Support of Claim for Service Connection for PTSD, the Veteran also stated that he experienced racial discrimination while serving on active duty. The Board notes that the Veteran has not been afforded a VA examination for psychiatric disorders. VA’s duty to assist includes providing a medical examination when it is necessary to decide a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). First, the record shows that the Veteran has been treated by Dr. A.B. for PTSD, severe anxiety, and bipolar disease. See Medical Treatment Record – Non-Government Facility, p. 1. Dr. A.B. is a physician who has treated the Veteran for over ten years. Id. Accordingly, the Board finds Dr. A.B to be competent to diagnose the Veteran with these disabilities and that the first element of McLendon is met. Second, the Veteran has provided testimony regarding several in-service stressors relating to psychiatric disorders, including onset of violent behavior, drug use, an eye injury during bootcamp, and racial discrimination. The Board has no reason to discredit the Veteran’s description of these events. Accordingly, the Board finds that the second element of McLendon to be met. Third, in the December 2014 Statement in Support of Claim for Service Connection for PTSD, the Veteran cited both his eye injury and racial discrimination in support of his claim. During the hearing, the Veteran was asked whether he experienced any mental health issues that arose during service. He responded that he displayed violent behavior while in the Philippines and that he had his first encounter with drugs. The Veteran’s statements indicate that a psychiatric disability may be associated with the in-service events and stressors he has described. Accordingly, the third element of McLendon is met. As all three McLendon elements are satisfied, the Veteran is entitled to a VA examination and medical opinion for psychiatric disorders. The matters are REMANDED for the following action: 1. Obtain any outstanding VA Medical Records, including but not limited to records from John Dingell VAMC. 2. Assist the Veteran in associating with the claims folder updated treatment records, including all private treatment records from Dr. A.B and Dr. A.M. All attempts to obtain these records pursuant to 38 C.F.R. § 3.159(c)(1) must be documented. 3. Thereafter, schedule the Veteran for a VA psychiatric examination to address the nature and etiology of any psychiatric disability, to include PTSD, anxiety disorder, and bipolar disorder. Any indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The entire claims file should be made available to the examiner designated to provide an opinion, and the examination report should include a discussion of the Veteran’s documented medical history and assertions. (a.) The examiner should identify all psychiatric disabilities diagnosed, including whether each criterion for a diagnosis of PTSD is met under DSM-5. (b.) If a PTSD diagnosis is deemed appropriate, the examiner should opine whether it is at least likely as not (50 percent or greater probability) that the Veteran’s PTSD diagnosis is linked to any reported in-service stressor. (c.) With respect to any diagnosed psychiatric disability other than PTSD, to include anxiety disorder and bipolar disorder, the examiner should opine whether it is at least likely as not that the psychiatric disability is related to the Veteran’s service. The examiner is advised that the Veteran is competent to report his history and symptoms and such reports must be considered. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Watkins, 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.