Citation Nr: 21004559 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 07-35 996 DATE: January 27, 2021 ISSUES Whether new and material evidence sufficient to reopen the claim for service connection for right and left heel spurs has been received, and if so should the claim be granted. Entitlement to for service connection for right and left heel spurs. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder and adjustment disorder. Entitlement to service connection for bilateral hernia disability. Entitlement to a temporary 100 percent/ total disability evaluation, because of treatment for a service-connected condition surgery requiring convalescence. Entitlement to a temporary 100 percent/total evaluation for a service -connected condition, requiring hospital treatment or observation in excess of 21 days. Entitlement to service connection for bilateral interstitial fibrosis as a result of asbestos exposure. ORDER New and material evidence sufficient to reopen the claim for service connection for right and left heel spurs has been received, and to that extent only, the claim is granted. Entitlement to a temporary 100 percent/ total disability evaluation, because of treatment for a service-connected condition surgery requiring convalescence is denied. Entitlement to a temporary 100 percent/total evaluation for a service -connected condition, requiring hospital treatment or observation in excess of 21 days is denied. Entitlement to service connection for bilateral interstitial fibrosis as a result of asbestos exposure is denied. REMANDED Entitlement to service connection for right and left heel spurs is remanded. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder and adjustment disorder is remanded. Entitlement to service connection for bilateral hernia disability is remanded. FINDINGS OF FACT 1. An October 2014 rating decision denied a claim for service connection for right and left heel spurs. 2. The Veteran filed a timely notice of disagreement (NOD) to the October 2014 rating decision in December 2014. However, in July 2015 the Veteran withdrew his December 2014 NOD. 3. The Veteran did not file another NOD or submit new and material evidence within the one-year appeal period following the October 2014 rating decision. 4. Evidence received since the October 2014 rating decision is not cumulative and redundant of the evidence previously of record and raises a reasonable possibility of substantiating the Veteran's claim of service connection for right and left heel spurs. 5. The preponderance of the evidence is against a finding that the Veteran underwent treatment for his service- connected knee disabilities, requiring convalescence. 6. The preponderance of the evidence is against a finding that the Veteran was hospitalized for treatment or observation in excess of 21 days due to his service- connected knee disabilities. 7. Bilateral interstitial fibrosis was not manifest in active service, or within one year of separation from service, and the preponderance of the evidence is against a finding that the Veteran was exposed to asbestos during service. CONCLUSIONS OF LAW 1. The October 2014 rating decision which denied service connection for right and left heel spurs is final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. New and material evidence sufficient to reopen the claim of service connection for right and left heel spurs has been received, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for the assignment of a temporary total rating based on need for a period of convalescence following surgery of the right and left knees have not been met. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. § 4.30. 4. The criteria for an assignment of a temporary 100 percent/total evaluation for service -connected right and left knee disabilities, requiring hospital treatment or observation in excess of 21 days have not been met. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. § 4.29. 5. The criteria for entitlement to service connection for bilateral interstitial fibrosis as a result of asbestos exposure have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.159, REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from December 1970 to February 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from August 2006, March 2017, March 2018 and December 2019 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran had three concurrent appeal streams- Docket number 0735996, Docket number 2001701 and Docket number 1836844. These appeals have been merged for the purposes of judicial economy and efficiency. See Board Directive 8430, ¶ 14 (a). The Board notes that the Veteran has other pending issues on appeal under Docket number 0735996, and these issues will be addressed by the Board in a separate, forthcoming decision. In March 2018 and August 2020, the Veteran was afforded videoconference Board hearings before the undersigned Veterans Law Judge (VLJ). A copy of the transcripts have been associated with the Veteran’s electronic claims folder. In January 2019, the Board issued a decision denying entitlement to service connection for an acquired psychiatric disability, to include anxiety and depression. In a September 2019 Joint Motion for Remand (JMR), the parties request clarification of the Board’s potential denial of the Veteran’s claim for entitlement to service connection for an acquired psychiatric disability. In that regard, it appears that there was a typographical error made in the Board’s January 2019 remand. Under the Remand section, it appears that the Veteran’s issue of entitlement to service connection for an acquired psychiatric disability was denied. However, the Board remanded all of the matters in its January 2019 remand. There is no record that the matter was adjudicated as denied. In fact, this decision acknowledges that the issue is still on appeal. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). With respect to claims to reopen, VA is further required to provide notice of the definition of new and material evidence. Kent v. Nicholson, 20 Vet. App. 1 (2006). However, VA is no longer required to provide notice of the element or elements that were found insufficient or the information and evidence necessary to substantiate the insufficient element or elements. See 38 U.S.C. § 5103(a)(1); VAOPGCPREC 6-2014 (Nov. 21, 2014); see also Akers v. Shinseki, 673 F.3d 1352, 1358 (Fed. Cir. 2012). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board.to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38U.S.C. §§1110, 1131; 38C.F.R. §3.303 (a). Generally, in order to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A disability deemed proximately due to or the result of a service-connected disease or injury shall be service connected ("secondary service connection"). 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). 1. Whether new and material evidence sufficient to reopen the claim for service connection for right and left heel spurs has been received. Petition to Reopen In October 2014, VA denied the Veteran’s original claim of entitlement for service connection for right and left heel spurs as secondary to his service-connected disability of retropatellar pain syndrome, left knee, residuals of torn medial meniscus. The Veteran filed a timely notice of disagreement (NOD) in December 2014. The RO issued a statement of the case (SOC) in July 2015. However, in July 2015 the Veteran submitted a VA Form 21-4138 and indicated that he wished to withdraw his December 2014 NOD for the denial of service connection for right and left heel spurs. The Veteran did not file another NOD or submit new and material evidence within the one-year appeal period following the October 2014 rating decision. He also did not assert there was clear and unmistakable error in the rating decision. Therefore, the October 2014 decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Veteran sought to reopen this claim in September 2018. The RO reviewed the Veteran’s claim file and denied reopening the claim in a February 2019 rating decision. The Veteran filed a NOD in March 2019. VA issued a SOC in December 2019. At that time the RO reopened the Veteran’s claim but denied the claim on the basis that the evidence did not indicate that the Veteran’s bilateral heel spurs were incurred in or related to his active service or a service- connected disability. The Veteran perfected an appeal to the Board in January 2020. The Board is required to address new and material claims in the first instance. The Board has the jurisdiction to address a new and material issue and to reach the underlying de novo claims. If the Board determines that new and material evidence has not been received, the adjudication of the particular claim ends, and further analysis is neither required nor permitted. Any decision that the AOJ may have made with regard to a new and material claim is irrelevant. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Thus, the Board will adjudicate this new and material issue in the first instance. New evidence is defined as existing evidence not previously submitted to VA since the last final denial, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2018). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Additionally, the United States Court of Appeals for the Federal Circuit has noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Only evidence presented since the last, final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273, 284 (1996). The Board considers the last, final denial to be the December 2019 rating decision for the bilateral heel spur service connection claim. For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, VA is not bound to consider credible the patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994). Claim Reopened The evidence of record in October 2014 consisted of service records, including personnel and medical records, a VA examination from October 2014 pertinent to the Veteran's right and left bone spur claims, other VA treatment records, and lay statements from the Veteran. The evidence of record at that time established diagnosis of bilateral bone spurs, but it did not establish a nexus back to service for the disability. Since the October 2014 rating decision for the bilateral heel spurs, the Veteran's file has additional VA medical records that have been attached to the claims file, to include a VA compensation and pension examination in December 2019 specifically for the right and left foot. These VA medical records show continuing treatment for the Veteran's left and right bone spurs. The Board also notes that the Veteran testified at the August 2020 Board hearing on the ongoing issues that he has related to this disability. This new evidence is not cumulative or redundant of the evidence previously of record. The Board is reminded in this regard that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). And further, that consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied. This newly received evidence basically provides a more complete picture as to the nature of the Veteran's bilateral heel spur disability in question, and under the low threshold standard could reasonably trigger the Secretary's duty to assist. Id. at 118. Therefore, assuming its credibility for the purpose of the threshold question of whether the claim can be reopened raises a reasonable possibility of substantiating the Veteran's claim of service connection for bilateral heel spur disabilities. As new and material evidence has been received, reopening of the previously denied claim of entitlement to service connection for bilateral heel spur disabilities is warranted. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). To that extent only, the claim to reopen for service connection for right and left heel spur disabilities is granted. 2. Entitlement to a temporary 100 percent/ total disability evaluation, because of treatment for a service-connected condition surgery requiring convalescence. The Veteran seeks a temporary 100 percent disability evaluation because of surgeries on his service-connected knees requiring convalescence. A temporary total disability rating will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under 38 C.F.R. § 4.30; effective the date of hospital admission or outpatient treatment and continuing for a period of one, two, or three months from the first day of the month following such hospital discharge or outpatient release. 38 C.F.R. § 4.30. A total rating will be assigned under 38 C.F.R. § 4.30 if treatment of a service-connected disability resulted in (1) surgery necessitating at least one month of convalescence; (2) surgery with severe post-operative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches; or (3) immobilization by cast, without surgery, of one major joint or more. Id. In December 2016 the Veteran filed a claim for a temporary total disability rating for surgery on his knees and indicated that the date of treatment was June 2016. In December 2016 correspondence the Veteran indicated that his private treatment provider would schedule surgery for the Veteran’s left knee sometime in January and that surgery for the right knee would be scheduled after the Veteran is rehabilitated from his left knee surgery. In January 2017 the RO sent the Veteran a letter informing him that his claim could not be processed until after the surgery and they received the treatment records for the surgery. The RO attempted to obtain the Veteran’s private treatment records in February 2017, however the RO received a response from the private treatment provider that there were no medical records to send because the Veteran was unable to keep his appointment. At a November 2017 VA examination the Veteran stated that he was unable to have knee surgery because his blood pressure was too high and that no other surgical attempts were made. After reviewing the evidence of record, the Board finds that the Veteran does not meet the criteria for a temporary total evaluation under 38 C.F.R. § 4.30. There is no evidence of convalescence or surgery for one of the Veteran's service-connected disabilities. Thus, as a matter of law a temporary total evaluation cannot be granted for the Veteran and a temporary total rating under 38 C.F.R. § 4.29 is not warranted. 3. Entitlement to a temporary 100 percent/total evaluation for a service -connected condition, requiring hospital treatment or observation in excess of 21 days. The Veteran seeks a temporary 100 percent disability evaluation because of surgeries on his service-connected knees requiring hospital treatment or observation in excess of 21 days. Under 38 C.F.R. § 4.29, a temporary total, or 100 percent rating is assigned when it is shown that a service-connected disability has required hospital treatment in a VA or VA-approved hospital for a period in excess of 21 days. This is true regardless of whether the hospital admission was for a service-connected disability, as long as hospital treatment for a service-connected disability is instituted and continued for a period of 21 days. 38 C.F.R. § 4.29 (b). As mentioned previously, the Veteran filed for a temporary total disability rating for surgery on his knees in in December 2016. However, the record reflects that the procedures were never performed, and no other surgical attempts were made. After reviewing the evidence of record, the Board finds that the Veteran does not meet the criteria for a temporary total evaluation under 38 C.F.R. § 4.29. The threshold requirement is that the surgery or period of hospital treatment be related to the treatment of a service-connected disability. There is no evidence of hospitalization for one of the Veteran's service-connected disabilities. Thus, a temporary total rating under 38 C.F.R. §§ 4.29 or 4.30 is not warranted. The appeal is denied as a matter of law. As the preponderance of the evidence is against this claim, the benefit of the doubt rule does not apply and the claim for entitlement to temporary total ratings based on need for convalescence or hospital treatment in a VA or VA-approved hospital for a period in excess of 21 days must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.30. 4. Entitlement to service connection for bilateral interstitial fibrosis as a result of asbestos exposure. The Veteran contends that he is entitled to service connection for his bilateral interstitial fibrosis due to asbestos exposure in service. The Board first notes that the Veteran’s service treatment records are silent for any bilateral interstitial fibrosis while in service. The Veteran's Report of Medical Examination upon separation does not show a diagnosis of any lung disease. The first indication of the Veteran suffering from any lung disease comes from a February 2017 private treatment note. The examiner noted primary and secondary t- type opacities in the Veteran’s mid and lower lung fields with a profusion of 1/0. The examiner’s impression was that the Veteran had a diagnosis of bilateral interstitial fibrosis which was directly related to asbestos provided that the subject’s exposure history and period of latency are appropriate. To the extent that the examiner has diagnosed the Veteran with interstitial fibrosis the Board finds that the Veteran has met the first prong of service connection; a current disability. However, the claim must be denied, as the Board finds that there is no in-service event or injury, as explained below. To begin, the Board notes that the Veteran first contended that he was exposed to asbestos while in active service on a June 2017 VA Form 21-4138. The Veteran's military personnel records indicate that for the period of time he was in active service he was a trainee who participated in basic combat training. As the Veteran's varied MOS in service does not confirm that he was exposed to asbestos in service, VA's duty to assist the Veteran in developing his claim includes verification of his stated exposure. As such, in August 2020 the AOJ sent a letter to the Veteran asking him where, when, and how he was exposed to asbestos; the names of other service persons who were with him at the time of such exposure; what other things that may cause cancer (cigarettes, chemicals, etc.) he was exposed to while in service and after service; and what type of work he did before and after service and how long he did each job. The Board notes that the Veteran never responded to the AOJ's inquiry. The duty to assist is not a one-way street; a claimant cannot remain passive when he has relevant information. See Wamhoff v. Brown, 8 Vet. App. 517 (1996) (VA has duty to assist the veteran, not a duty to prove his claim while the Veteran remains passive). Therefore, the only evidence of record regarding whether the Veteran was exposed to asbestos in service is his own statement stating that he was exposed to asbestos in his barracks. The Board notes that the February 2017 private examiner attributed the Veteran’s current disability to asbestos exposure, but that opinion was based only on the Veteran’s self- reporting of exposure and was also contingent on the Veteran’s report being accurate information. While the Veteran is competent to describe his assignment that fact that there is no record of any such exposure reduces the credibility of his statement. Further, the Veteran's statement is the only evidence of record that the barracks actually contained asbestos, and the Veteran has not demonstrated that he has any expertise qualifying him to otherwise identify asbestos building materials. Accordingly, the Board finds there is no credible evidence that the Veteran was exposed to asbestos during service. Finally, the duty to assist requires VA to provide an examination when the record contains competent evidence the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with military service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 21 Vet. App. 23 (2007). Here, as the Board finds there is insufficient evidence that the Veteran was exposed to asbestos during service, the record does not indicate that his current disability may be associated with military service; therefore, no VA examination is necessary. Accordingly, the preponderance of the evidence is against a finding that the Veteran’s bilateral interstitial fibrosis is causally related directly to any aspect of service, and the appeal must be denied. As the preponderance of the evidence is against the appeal, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 REASONS FOR REMAND 1. Entitlement to service connection for right and left heel spurs is remanded. The Board finds that further development is necessary prior to final adjudication of the Veteran's claim for entitlement to service connection for right and left heel spurs. At the outset, the Board notes that in July 2020 correspondence the Veteran, through his attorney, requested the curriculum vitae (CV) and the personnel files for the VA examiners who have examined the Veteran. The issue was raised again at the August 2020 Board hearing. At that time the undersigned Veterans Law Judge informed counsel that VA would attempt to obtain this information. Therefore, pursuant to the Veteran's request, the claim should be remanded to attempt to locate the requested records and associate them with the claims file. See Nohr v. McDonald, 27 Vet. App. 124 (2014). 2. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder and adjustment disorder is remanded. The Veteran contends that he is entitled to service connection for an acquired psychiatric disability because he witnessed 2 fellow Marines attempted suicide. He testified at the August 2018 Board hearing that he did not witness the actual attempted suicide because he turned away but believes that they shot themselves in the leg. He further testified that he experienced nightmares as a result of the incident. In December 2018 the Veteran, through his representative, submitted a psychiatric evaluation from Dr. Q.A.S. that said“[i]n regards to PTSD symptoms, [the Veteran] was noted to list PTSD symptoms verbatim from DSM, but was not able to describe how these symptoms impacted his life or give examples beyond nightmares he experienced.” Dr. Q.A.S. opined that the Veteran did not meet the criteria for PTSD. However, he found that the Veteran does suffer from adjustment disorder. He cites to the Veteran’s drafting into service as the precipitating event to the adjustment disorder. He also cites to the Veteran’s subsequent failed career in the military and post-military career as a social worker as events which contributed to the Veteran’s psychiatric symptoms. The Veteran reported that he suffered from sleep deprivation; depression and anxiousness about going to Vietnam while in service. He stated that due to his inability to sleep, he drank cough syrup. Dr. Q.A.S. noted that the Veteran “continues to demonstrate similar symptoms currently.” Dr. Q.A.S. continues his opinion by stating that, “While [the Veteran’s] adjustment disorder appears to have improved after military release, it does not appear to have ever completely abated. When [the Veteran’s] service-connected difficulties of knee injuries worsened, and he was unable to work due to knee and subsequent back issues, his depression did markedly increase.” Based on the foregoing statement, it appears Dr. Q.A.S. is attempting to establish that the Veteran’s adjustment disorder may be secondarily related to his service-connected knee disability. However, the opinion falls short of being adequate to support a nexus between the two. Dr. Q.A.S. does not opine whether he believes the Veteran’s service-connected knees caused or aggravated the Veteran’s adjustment disorder. The Board must address all theories of entitlement raised by a claimant or reasonably raised by the record. See Robinson v. Peake, 21 F.3d 545, 553 (Fed. Cir. 2008). Therefore, the Board finds that a remand is necessary to obtain a medical opinion which addresses secondary service connection. 3. Entitlement to service connection for bilateral hernia disability is remanded. The Veteran contends that his bilateral hernia disability is related to his active service, to include as secondary to his service-connected bilateral knee disabilities. In August 2017 the Veteran filed a claim for entitlement to service connection for a “Bilateral Hernia-Surgery Twice”. His service treatment records reflect that he had a past hernia surgery in 1993. At the August 2020 Board hearing the Veteran testified that he has had a more recent hernia surgery sometime in 2014. The Veteran further testified that he had ongoing issues related to his hernia condition. Additionally, the Veteran testified that he believed that his hernia disability is related to service-connected right and left knee disabilities because, due to his issues with his lower body, he uses his upper body more for weight and balance. Based on the Veteran’s testimony, the issue has been recharacterized as reflected on the Cover Page of this decision to more accurately reflect the Veteran's contentions of a hernia disability. See, e.g., Clemons v. Shinseki, 23 Vet. App. 1 (2009). Based on the Veteran’s testimony he has raised the issue that his hernia disability is secondarily related to his service-connected right and left knee disabilities. The Board notes that the Veteran has not been provided with a VA examination for his bilateral hernia disability nor has he been provided with a medical opinion to address the issue of etiology. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i) (2017). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. Here, the Board finds that the McLendon criteria have been satisfied. Specifically, there is competent evidence that the Veteran has a bilateral hernia disability which may be associated with his active service, including as secondary to his service connected bilateral knee disabilities, but there is insufficient competent medical evidence on file for the Board to make a decision on the claim. As such, remand for an examination and medical opinion is necessary. The matters are REMANDED for the following action: 1. Make appropriate efforts to obtain and associate with the claims file any updated VA medical records of the Veteran not previously obtained. 2. Obtain from the Veteran's attorney a succinct list of the VA examiner(s) and then locate the resume/CV of the indicated VA examiner(s). Associate these records with the claims file and provide the Veteran and his attorney with a copy. If any of these records are found to be unavailable, this should be specifically noted in the claims file and the Veteran should be notified as to the unavailability of such records pursuant to 38 C.F.R. § 3.159 (e). To ensure substantial compliance with this remand directive, the RO should at least clarify the specific nature of the examiner(s) professional qualifications. 3. Schedule the Veteran for a VA psychiatric examination to determine the etiology of his claimed psychiatric disabilities. A copy of the Veteran's electronic claims folder, including a copy of this remand, must be provided to the examiner. All findings should be described in detail and all necessary diagnostic testing performed. The examiner should provide an opinion on the following: (a) Whether it is at least as likely as not that the Veteran has a diagnosis of PTSD in accordance with the DSM-5 diagnostic criteria that is related to service. (b) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has an acquired psychiatric disorder other than PTSD, in accordance with the DSM-5 diagnostic criteria that is related to events in service as described by the Veteran. (c) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran has an acquired psychiatric disorder other than PTSD that was caused or aggravated by his service-connected bilateral knee disabilities. The examiner should address Dr. Q.A.S.'s psychiatric evaluation where he states, "While [the Veteran's] adjustment disorder appears to have improved after military release, it does not appear to have ever completely abated. When [the Veteran's] service-connected difficulties of knee injuries worsened, and he was unable to work due to knee and subsequent back issues, his depression did markedly increase." The examiner must also remain mindful that a recent precedent case clarified that secondary service connection does not require "permanent" worsening of the condition being claimed by the service-connected disability and requires considering whether there has been any worsening, no matter how incremental, so even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). If aggravation is found, provide the baseline manifestations prior to aggravation and the increased manifestations. A complete rationale for all opinions must be provided. 4. Schedule the Veteran for a VA examination by an appropriate clinician to determine the etiology of his bilateral hernia disability. A copy of the Veteran's electronic claims folder, including a copy of this remand, must be provided to the examiner. All findings should be described in detail and all necessary diagnostic testing performed. The examiner should provide an opinion on the following: (a) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hernia is at least as likely as not related to an in-service injury, event, or disease. (b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hernia disability was caused or aggravated by his service-connected bilateral knee disabilities. The examiner should address the Veteran’s lay assertions that due to his issues with his lower body he uses his upper body more for weight and balance. The examiner must also remain mindful that a recent precedent case clarified that secondary service connection does not require "permanent" worsening of the condition being claimed by the service-connected disability and requires considering whether there has been any worsening, no matter how incremental, so even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). 5. If aggravation is found, provide the baseline manifestations prior to aggravation and the increased manifestations. (Continued on next page.) 6. After completing the above development, and any other development deemed necessary, readjudicate the issues on appeal. If any benefit sought remains denied, provide an SSOC to the Veteran and his attorney, and return the appeal to the Board for appellate review after the Veteran has an adequate opportunity to respond. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Nettey, 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.