Citation Nr: 21003567 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 14-12 022 DATE: January 22, 2021 REMANDED Entitlement to service connection for left shoulder condition, to include as secondary to residual gunshot wound of the right upper chest muscle group IV with residual foreign body, is remanded. Entitlement to service connection for low back condition, to include as secondary to residual gunshot wound of the right upper chest muscle group IV with residual foreign body, is remanded. Entitlement to service connection for peripheral vascular disease, to include dementia, vascular type with depressive features is remanded. Entitlement to service connection for frostbite residuals in all extremities is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an acquired psychiatric disorder, including depressive disorder and post-traumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from October 1951 until his honorable discharge in September 1953. He is a Korean War Veteran. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision of the Regional Office (RO) of the Department of Veterans Affairs (VA). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.902(c). In March 2016, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain private and VA treatment records, Social Security Administration records, and addendum medical opinions. The claim returned to the Board and was remanded again in July 2017 for VA medical examinations. Again, in March 2019, the claim was remanded in order to obtain treatment records of the Veteran’s August 2017 hospitalization, updated VA treatment records, and addendum medical opinions. A finding of incompetency was proposed in a March 2012 rating decision and the Veteran was notified of this finding. In the November 2012, the Veteran filed a request for appointment of a fiduciary, custodian or guardian, naming his granddaughter, Ms. M.R. as the fiduciary and listing her address as the point of contact due to a final November 2012 rating decision finding that he was not competent to handle disbursement of funds due a lack of mental capacity. In December 2012, VA Fiduciary Hub created a Certificate of Legal Capacity to Receive and Disburse Benefits. In a December 2013 correspondence, the Veteran’s fiduciary informed the Agency that the Veteran is bedridden. In March 2017, an updated Certificate of Legal Capacity to Receive and Disburse Benefits was added to the record, naming Mr. J.S., as the payee, along with a new address. Yet, no accompanying appointment of a fiduciary form was filed. 1. Entitlement to service connection for left shoulder condition, to include as secondary to residual gunshot wound of the right upper chest muscle group IV with residual foreign body. 2. Entitlement to service connection for low back condition, to include as secondary to residual gunshot wound of the right upper chest muscle group IV with residual foreign body. 3. Entitlement to service connection for peripheral vascular disease, to include dementia, vascular type with depressive features is remanded. 4. Entitlement to service connection for frostbite residuals in all extremities. 5. Entitlement to service connection for headaches is remanded. 6. Entitlement to service connection for an acquired psychiatric disorder, including depressive disorder and post-traumatic stress disorder (PTSD). 7. Entitlement to a total disability rating based on individual unemployability. Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. Although the Board regrets the additional delay, the claim must be remanded for a supplemental statement of the case (SSOC) to be filed by the RO. Procedural Due Process Further development of appeal must be undertaken to ensure that the Veteran is afforded due process. Specifically, under 38 C.F.R. § 19.31, the agency of original jurisdiction (AOJ) will provide a supplemental statement of the case (SSOC) to the appellant and his representative when there are any material changes in, or additions to, the information included in the statement of the case (SOC) or any prior SSOC, to include the receipt of additional pertinent evidence. Here, the record indicates that additional VA treatment records and addendum VA medical opinions were associated with the claims file after the most recent remand and no SSOC was filed before the claim was certified to the Board in December 2020. Accordingly, the appropriate Board action is to remand the Veteran's claims to the RO for issuance of an SSOC. 38 C.F.R. § 19.37(b)(1). Adequate VA Examination VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes providing a medical examination when necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The March 2019 remand instructed the examiner conducting the psychiatric addendum opinion to “indicate whether the Veteran meets the DSM-5 criteria for each diagnosis.” This was not done. The matters are REMANDED for the following action: 1. Return the record to the VA examiner who conducted the Veteran’s January 2020 VA psychiatric addendum opinion and obtain a clarification to ensure that the diagnoses provided meet the DSM 5 criteria, if possible. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a SSOC and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. 3. Should VA examinations be requested, send a notice to the Veteran’s fiduciary, Ms. M.R. explaining the necessity of the examination and that failure to report could result in discontinuance or reduction of benefits. E mail a request for assistance in having the Veteran report for the examination to the mailbox of the fiduciary hub of jurisdiction. Allow the Veteran the opportunity to provide a statement, should there be good cause, as to why the Veteran is unable to attend the requested VA examinations. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Johnston, 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.