Citation Nr: 21004806 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 10-09 169 DATE: January 28, 2021 REMANDED Entitlement to service connection for tremors of the bilateral upper extremities, to include essential tremors, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from June 1965 to June 1967; he was a medic. The evidence of record establishes that the Veteran was awarded the Combat Action Ribbon and participated in at least two operations in the Republic of Vietnam in 1967. Thus, the Board finds that the Veteran has been exposed to herbicides during his service. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2009 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter has been previously remanded for further development in January 2015, May 2016, December 2017 and June 2019. In its June 2019 order, the Board denied service connection for peripheral neuropathy of his upper extremities and remanded the issue of service connection for his bilateral hand tremors for additional development. Specifically, the Board ordered a new VA examination to determine the nature and etiology of the Veteran's bilateral upper extremity tremors and required the examiner to opine whether these tremors were at least as likely as not related to an in-service injury or disease, including exposure to contaminated water at Camp Lejeune. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand. Stegall v. West, 1 Vet. App. 268, 271 (1998). Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. As such, another remand is warranted. In September 2020, the Veteran underwent a VA peripheral nerve condition examination by a contractor. However, the VA examiner did not offer an opinion as to whether they were related to an in-service injury or disease, including exposure to contaminated water at Camp Lejeune. The examiner first indicated that a peripheral nerves examination was not appropriate, as tremors were related to central nervous system dysfunctions. No effort was made to perform the appropriate examination, however. Further, the examiner indicated some information was missing from the examination request, and due to that omission, no opinion could be offered. This is puzzling, as the contractor also stated he had reviewed the claims file in its entirety, and so had all available information for consideration. On remand, an adequate and appropriate examination must be secured. Additionally, review of the claims file reveals that the Veteran contends that herbicide exposure in Vietnam and in-service lead exposure (via bullets and barracks paint) caused his essential tremors and that the Veteran received treatment for this condition from a private neurologist. As noted above, the Board has found that the Veteran was present in Vietnam during his active duty service and therefore, herbicide exposure is established. Exposure to ammunition and lead-based paint is also highly likely. However, the Veteran's contentions have not been developed or considered. The matters are REMANDED for the following action: 1. Contact the Veteran and request properly executed, separate VA form 21-4142’s, Authorization and Consent to Release Information to the Department of Veterans Affairs, for any private care providers who have treated him for his essential tremors, including a private neurologist referenced in VA and private treatment notes. Upon receipt of such, VA must take appropriate action to contact the identified providers and request complete treatment records. The Veteran should be informed that in the alternative he may obtain and submit the records himself. 2. Then, schedule the Veteran for a Central Nervous System and/or Seizure Disorders examination with a clinician other than he who conducted the September 2020 contract examination. The claims folder must be reviewed in its entirety in conjunction with the examination. The examiner must identify all current neurological or neuromuscular conditions which are present; the cause of currently diagnosed essential tremors and a seizure disorder must be specifically addressed. For each diagnosed condition, the examiner must opine as to whether such is at least as likely as not caused or aggravated by exposure to contaminated water at Camp Lejeune, by exposure to tactical herbicides (e.g., Agent Orange) in Vietnam, or exposure to the heavy metal lead in ammunition and paints in service. A full and complete rationale for any opinion expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Then, readjudicate the claim on appeal. If any benefit sought remains denied, issue an appropriate supplemental statement of the case and return the appeal to the Board if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Megan-Brady Viccellio 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.