Citation Nr: 21003613 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 16-20 984 DATE: January 22, 2021 REMANDED The issue of service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active service from December 1982 to February 1986 and November 1986 to March 1988. The issue was previously before the Board. In October 2018, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. Specifically, the Board directed the AOJ to schedule a new VA examination for the Veteran’s alleged PTSD. The Board also directed the VA examiner to comment as to whether the reports by the Veteran’s mother in a June 2016 communication regarding the Veteran’s behavioral changes after service tend to corroborate the occurrence of the claimed in-service sexual assault. Following evidentiary development, the VA Appeals Management Center (AMC) continued the previous denials in a supplemental statement of the case (SSOC) issued in April 2020. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. In September 2020, the Veteran’s attorney requested a 90 day extension to submit further evidence and argument in support of his appeal. The request was granted in September 2020 and the Veteran’s attorney submitted an argument in October 2020. No additional evidence or argument was submitted, and the 90-day period has expired. The issue of service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. As an initial matter, the Board notes that there is an obligation to construe a claim for a psychiatric disorder liberally to include all psychiatric disorders found. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (scope of mental health disability claim may include any mental disability that may be reasonably be encompassed by the claimant’s description of the claim, symptoms, and other information of record). Here, although the Veteran’s claim was for PTSD, the Board construes it as a claim for an acquired psychiatric disorder. 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). Also, when a VA examination is provided or when a VA opinion is obtained, the VA must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As discussed above, in an October 2018 decision, the Board directed the AOJ to schedule a new VA examination and the examiner to specifically comment on the Veteran’s mother’s June 2016 report. The July 2019 VA examiner mentioned the June 2016 report from the Veteran’s mother, but did not specifically comment whether the Veteran’s behavioral changes after service tend to corroborate the occurrence of the claimed in-service sexual assault as directed by the Board. In her rationale, the examiner cited the contents of the June 2016 report, but did not specifically state whether it corroborated the occurrence of the claimed in-service sexual assault. Instead, the examiner seemed to give more weight to the lack of self-reported symptoms in September 1987 and the lack of evidence of “potential markers related to military sexual trauma” as she concluded that there was no sufficient, evidence-supported association between the Veteran’s symptoms and “alleged military sexual trauma.” The examiner did not explain why the June 2016 report could not be considered as a “potential marker,” did not discuss the statement made by the other soldier to whom the Veteran confided after the contended military sexual trauma, and did not state if records of “symptoms associated with depression, nervousness, or worry” would be sufficient to establish a relationship between the Veteran’s symptoms and the contended military sexual trauma. Another VA examiner opined on the Veteran’s diagnosed Other Specified Trauma and Stressor Related Disorder in February 2020, but also did not comment whether the Veteran’s behavioral changes after service, as reported by the Veteran’s mother in June 2016, tend to corroborate the occurrence of the claimed in-service sexual assault as directed by the Board. Instead, the examiner merely reiterated that the Veteran did not meet the criteria for PTSD based on the June 2019 VA examination and repeated the findings of the June 2019 VA examiner. As neither VA examination followed the directives of the October 2018 Board decision, an addendum opinion is required as to the nature and etiology of the Veteran’s Other Specified Trauma and Stressor Related Disorder commenting on whether the reports by the Veteran’s mother in a June 2016 communication regarding the Veteran’s behavioral changes after service tend to corroborate the occurrence of the claimed in-service sexual assault. The matter is REMANDED for the following action: Obtain an addendum opinion from mental health professional regarding the etiology of the Veteran’s acquired psychiatric disorder. The Veteran’s claims file should be made available to the clinician. The examiner should provide an opinion with supporting rationale. The need for another examination is left to the discretion of the examiner offering the addendum opinion. The examiner must specifically comment as to whether the reports by the Veteran’s mother in a June 2016 communication regarding the Veteran’s behavioral changes after service, and the September 2016 affidavit by another servicemember, tend to corroborate the occurrence of the claimed in-service sexual assault. The examiner is asked to discuss the June 2016 and September 2016 statements even if the clinician determines that the Veteran’s acquired psychiatric disorder is not related to his service or any other incidents therein. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Yun 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.