Citation Nr: 21062529 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 16-34 884 DATE: October 7, 2021 REMANDED Entitlement to special monthly compensation (SMC) based upon need for the regular aid and attendance of another person is remanded. Entitlement to a certificate of eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment, or automobile adaptive equipment only, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1969 to September 1970, November 1971 to November 1973, and September 1974 to September 1977, with additional National Guard service thereafter. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal was last before the Board in August 2020 at which time additional evidentiary development was requested to comply with due process requirements. Unfortunately, based upon medical evidence added following that remand, the Board finds that additional medical questions have arisen, answers to which are necessary to fairly adjudicate the Veteran's claim. Although the Board sincerely regrets the further delay, an additional remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran's claims so that every possible consideration is afforded. 1. Entitlement to SMC based upon need for the regular aid and attendance of another person is remanded. 2. Entitlement to a certificate of eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment, or automobile adaptive equipment only, is remanded. The Veteran reports that he needs the aid and assistance of another person, and qualifies for financial assistance in automobile adaptation because he is legally blind. See, e.g., VA examination for housebound status or permanent need for regular aid and attendance, June 2011. Service connection is in effect for traumatic optic neuropathy of the left eye, rated as zero percent disabling, and for shell fragment wound scars with retained foreign body above the left eye, also rated as zero percent disabling. Service connection has not been established for "blindness" although the now service-connected left eye disorder was originally claimed as such. However, the evidence raises a question as to whether the Veteran's blindness is secondary to his service-connected psychiatric disability, and this question should be addressed as part and parcel of the increased rating claim for additional SMC that has been perfected for the Board's review. The matter of the Veteran's visual acuity is also necessary to establish entitlement to automobile adaptation benefits. The prior August 2020 Board remand, which also included the issue of service connection for the Veteran's left eye disability, directed that an opinion from a neurologist was needed to address the Veteran's variously diagnosed eye disabilities, claimed as blindness. Consequently, a medical opinion was obtained in September 2020 in which the opining neurologist found that the evidence "suggests but does not define a possible functional eyesight disorder." See also Dorland's Illustrated Medical Dictionary 760 (31st ed. 2007) (defining functional in this context as affecting the function but not the structure of the eye). The neurologist then recommended "a complete ophthalmologic and psychiatric evaluation which may further define [the Veteran's] condition." VA medical opinion, September 2020. An October 2020 VA examination was then conducted to determine the severity of the Veteran's service-connected posttraumatic stress disorder (PTSD), but this examination did not address the potential psychiatric origin of the Veteran's functional blindness. The Veteran was not cooperative during this examination, presented as irritable and impatient, informed the examiner that he was only willing to participate for 30 minutes and refused to answer questions for which he believed answers could be found in his medical records. This examination report ultimately only discussed the Veteran's blindness in terms of the Veteran's self-report of his medical conditions and use of a cane for the visually impaired, but did not address any functional or psychiatric component of the Veteran's blindness. Of note, the Veteran's 100 percent disability rating for PTSD already includes consideration and compensation for headaches secondary to somatization disorder. See Rating decision, November 1996. Somatization disorder is defined as "a mental disorder characterized by multiple somatic complaints that cannot be fully explained by any known general medical condition or the direct effect of a substance, but are not intentionally feigned or produced...." Dorland's Illustrated Medical Dictionary 560 (31st ed. 2007). This is found to lend additional weight to the need to address whether the Veteran's functional blindness is secondary to or a component of his service-connected PTSD in order to warrant the SMC sought because of blindness. A June 2021 opinion from an optometrist reiterates that although the Veteran reports light perception only in his right eye and no light perception in his left eye, previous testing (normal visual evoked potential (VEP), electroretinography (ERG), and dark adaptation thresholds) reflects that there is "nothing organically wrong with his eyes" and although there is a mild pallor of the left optic nerve which could impact vision, it is not consistent with the reported complete vision loss and would not cause loss of vision in the unaffected right eye. Ultimately, this examiner also appears to find some functional component to the Veteran's vision loss, and relates the prior examiner's reference that psychiatry may be a specialty that could assist in this case. VA opinion, June 2021. Considering the record as a whole, the Board finds that to accurately adjudicate the Veteran's claimed entitlement to SMC on the basis of his blindness, a medical opinion is necessary to determine whether or not the Veteran's functional blindness is secondary to his service-connected psychiatric disorder, and to determine whether the Veteran requires care or assistance on a regular basis to protect himself from the hazards or dangers incident ot his daily environment and other factors defined in 38 C.F.R. § 3.352 as criteria for determining an individual's need for aid and assistance. Based upon the Board's prior remand, the Veteran was also scheduled for ophthalmology examination, but he declined to attend the scheduled evaluation due to concerns about a potential for eye infection. The Board notes that the Veteran has refused to fully participate in multiple eye examinations performed by VA during the appeal for various and inconsistent reasons provided by the Veteran. See, e.g., VA treatment, September 2015 & August 2013; Veteran's statement, November 2020. The Veteran is reminded that eligibility for financial assistance for automotive adaptive equipment is based on permanent impairment of vision in both eyes as demonstrated by specific visual acuity measurements. 38 C.F.R. § 3.808(b)(3). Although VA has a duty to assist the Veteran in obtaining this evidence, it is a two-way street and the Veteran must cooperate fully with VA's reasonable efforts to obtain evidence in support of his claim. See, e.g., Wood v. Derwinski, 1 Vet. App. 190 (1991); see also 38 C.F.R. § 3.655. Also, the Veteran reports receiving treatment by private providers for eye conditions, and he may submit these records to support his claim or ask VA to obtain them on his behalf. The Board encourages the Veteran to fully cooperate in any examinations scheduled as a result of this remand because the evidence necessary to substantiate his claims is not present at this time. It is important to note that this is in no way an effort to disprove the Veteran's blindness as a true functional impairment that this Veteran faces. Instead, it is clear that the Veteran's vision loss impairs his day-to-day functioning in significant ways. The examinations requested here have the intent to more clearly define that impairment of functioning and determine whether the vision loss is attributable to an already service-connected disability. Nonetheless, if the Veteran fails to cooperate with examiners, or refuses to answer questions and participate fully in any examination scheduled by VA, then VA will have no further duty to assist in obtaining evidence and may ultimately deny the Veteran's claim. The matters are REMANDED for the following action: 1. Provide the Veteran ONE additional opportunity to report for an eye examination. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider those symptoms to be a disability for the purpose of providing the requested opinion. Does the Veteran have "permanent impairment of vision of both eyes" as demonstrated by central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye? Provide a thorough medical rationale to support the opinion offered. 2. Schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of the Veteran's functional blindness and/or somatization disorder as may be related to his vision (from a psychiatric perspective only as opposed to any organic eye pathology). The examiner must review the claims file. The Board recognizes that the complex nature of the medical questions involved in this case will require significant work on the part of the examiner. Full and thoroughly explained answers to each of the questions will prevent further delays in adjudication and are very much appreciated. (a.) Is the Veteran's functional blindness at least as likely as not proximately due to his service-connected PTSD with headaches secondary to Somatization Disorder? Why or why not? (Continued on the next page) (b.) Is the Veteran's functional blindness at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected PTSD with headaches secondary to Somatization Disorder? Why or why not? 3. After completion of the above, schedule the Veteran for a VA examination to determine and record manifestations of his service-connected disabilities pertinent to the Veteran's need for the regular aid and attendance of another person. The Board notes evidentiary disparities in this regard, and the examiner's attention is invited to the June 2011 VA aid and attendance examination as contrasted with the October 2017 treatment note that the Veteran's wife "is only able to assist him sixty percent of the time" and the January 2018 treatment notation that describes the Veteran's blindness as "an inconvenience" but that the Veteran is able to "feed self, walk, go to the bathroom and more." The examiner is asked to describe in thorough detail the Veteran's ability or inability to dress or undress, keep himself ordinarily clean and presentable, attend to the wants of nature, and his incapacity (whether physical or mental) which requires care or assistance on a regular basis to protect himself from the hazards or dangers incident to his daily environment. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDonald, 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.