Citation Nr: 21062954 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 18-30 772 DATE: October 12, 2021 REMANDED Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for scarlet fever is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1976 to May 1979. In December 2020, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board notes that the Veteran has submitted statements with respect to his financial hardship. Given such, the Board has liberally constructed these statements as a Motion to Advance his appeal based on financial hardship. The undersigned Veterans Law Judge grants such motion, and this appeal is therefore advanced on the docket. 38 C.F.R. § 20.900 (c). For the reasons discussed below, the Board finds that further development is warranted. Outstanding Records PTSD At the onset, the Board notes that during the Veteran's December 2020 Board hearing, the Veteran testified that he receives Social Security Administration (SSA) disability benefits for this mental health condition. However, the Veteran's SSA records have not been requested. The Veteran's SSA records might contain additional treatment records, medical opinions, and other evidence that could be relevant to the issues on appeal. Accordingly, VA should undertake efforts to obtain the Veteran's SSA records. 38 C.F.R. § 3.159 (c) (2); see also Golz v. Shinseki 590 F.3d 1317 (Fed. Cir. 2010) (VA has an obligation to secure Social Security records if there is a reasonable possibility that the records would help to substantiate the Veteran's claim). Furthermore, in a January 2021 VA medical report, the examiner noted that the Veteran has been treating at Savannah VA clinic since July 28, 2015. However, the record does not include any records from the Savannah Outpatient Clinic after April 2016. As such, VA should undertake efforts to obtain updated records from the Savannah VA clinic. VA examinations PTSD The Board notes that the Veteran has yet to be afforded a VA examination with respect to his PTSD. The Veteran has submitted several claimed in-service stressors, which appear to be potentially related to the Veteran's fear of hostile military or terrorist activity. As such, the Board finds that a VA examination is warranted. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Scarlet Fever Here, the Veteran's separation examination report reflects that the Veteran had scarlet fever as a child. However, his entrance examination report does not note scarlet fever upon entrance. Furthermore, the Veteran contends that he did not have scarlet fever as a child. He contends that he caught scarlet fever in late 1976 or early 1977. See June 2018 VA Form 9. While the Veteran's medical records do not reflect a current diagnosis of scarlet fever, the Veteran contends that he has scarlet fever, and it is not something that "goes away." The Board notes that the Veteran's service treatment records reflect that he was treated for cold-like symptoms during his service. The Board acknowledges that the Veteran's service treatment records do not "note" scarlet fever upon entrance to service. Hence, scarlet fever was not "recorded in an examination report" at entry within the meaning of 38 C.F.R. § 3.304(b). Given such, the Board finds that the presumption of soundness attaches with respect to the Veteran's claim for scarlet fever. Under 38 U.S.C. § 1111 and 38 C.F.R. § 3.304 (b), the presumption of soundness may be rebutted by clear and unmistakable evidence that an injury or disease existed prior to service. Given such, the Board finds that the finding in the Veteran's separation report that he had childhood scarlet fever makes it unclear as to whether the Veteran's scarlet fever preexisted service. Consequently, the Board finds that a clarifying opinion from a VA examiner is warranted. Bilateral Hearing Loss Here, in a March 2016 VA examination report, the VA examiner diagnosed the Veteran with bilateral hearing loss and opined that the Veteran's bilateral hearing loss is less likely than not related to his in-service noise exposure. The Board notes that the VA examiner found that the Veteran's right ear hearing loss preexisted service. The examiner noted that the Veteran's entrance examination report reflected high frequency moderately severe hearing loss in the right ear. The Veteran contends that he first noticed his hearing loss in 1978 and 1979 (during service). He reported the onset was gradual. While the VA examiner opined that the Veteran's preexisting service was not aggravated by service because the "thresholds [are] stable from enlistment to separation," the Board notes that at separation the Veteran's hearing acuity level was 50 decibels at 3000 hertz. His entrance examination report is silent for puretone thresholds at 3000 hertz. Given the high pure-tone decibels at 3000 hertz at separation, it is unclear if that high pure-tone threshold at separation is evidence that the Veteran's right ear hearing loss was clearly and mistakenly aggravated by his service. As such, an addendum opinion is warranted. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any outstanding records relevant to the Veteran's claims on appeal, to include: (a.) Medical records from SSA with respect to disability benefits related to the Veteran's claims on appeal; and (b.) Medical records from Savannah VA clinic from April 2016. All attempts to obtain these records must be documented in the claims file. The RO should follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159 (c). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). 2. Once the above development has been completed, with respect to the Veteran's claim for PTSD, schedule the Veteran for a VA examination with a qualified VA psychologist or psychiatrist to determine the etiology of the Veteran's PTSD. After performing any required tests, and reviewing the entire record, the examiner should provide an opinion responding to the following: (a) Whether the Veteran's PTSD is at least as likely as not related to his claimed in-service stressors, to include whether related to his fear of hostile military or terrorist activity. "[F]ear of hostile military or terrorist activity' means that the veteran experienced, witnesses, or was confronted with an event or circumstance that involved actual or threaten death or serious injury, or a threat ot the physical integrity of the veteran or others, such as an actual or potential improvised explosive device, vehicle-imbedded explosive device, incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror." In providing this opinion, the examiner is asked to address the Veteran's lay statements to include: a) The Veteran contends that there was an incident that occurred a year before he arrived in Korea, called the Hatchet Incident, which involved an argument over a tree, which resulted in people being killed; b) The Veteran contends that there were several mines and body traps in Korea, and he was always afraid; c) The Veteran contends that he was on high alert due to conflict between the North and South Koreans over a fishing boat; d) The Veteran contends that he was lost in the jungle for a day during training; e) The Veteran contends that a helicopter was shot down and 3 US soldiers were killed, and he saw their bodies; f) The Veteran contends that South Koreans came to his camp one night and threw blankets on him and beat them; and g) The Veteran contends that North Koreans built a tunnel under ground and kidnaped US soldiers 3. With respect to the Veteran's scarlet fever claim, request an opinion from a qualified medical examiner that addresses the following. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. (a.) Whether the Veteran has a current diagnosis of scarlet fever. If the examiner determines that the Veteran does not have a diagnosis of scarlet fever, please address the etiology of scarlet fever and whether it is a permanent disease that once contracted does not resolve. (b.) If the examiner determines that the Veteran has a current diagnosis of scarlet fever, (a) Did the Veteran's scarlet fever clearly and unmistakably (obviously or manifestly) exist prior to entrance into service? (c.) If it is the VA examiner's opinion that the Veteran's scarlet fever clearly and unmistakably preexisted service, was any preexisting scarlet fever disability clearly and unmistakably (obviously or manifestly) not aggravated (not worsened beyond the natural progression) during active service? The term "aggravated" means an increase in severity of the underlying disability that is not due to the natural progress of the disease. (d) If the Veteran's scarlet fever did not clearly and unmistakably preexist service, whether it was at least as likely as not that the Veteran's scarlet fever was due to or otherwise etiologically related to the Veteran's active service. The examiner is asked to address the Veteran's contentions that he developed scarlet fever during service, in 1976 or early 1977. 4. With respect to the Veteran's bilateral hearing loss, obtain an opinion from an appropriate medical physician. The claims file, to include this Remand and the claims file must be made available to and reviewed by the examiner, and a note that it was reviewed should be included in the report. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. After reviewing the claims file, the reviewer should answer the following questions: (a) Did the Veteran's right ear hearing loss clearly and unmistakably (obviously or manifestly) exist prior to entrance into service? (b) If it is the VA examiner's opinion that the Veteran's right ear hearing loss clearly and unmistakably preexisted service, was any preexisting right ear hearing loss clearly and unmistakably (obviously or manifestly) not aggravated (not worsened beyond the natural progression) during active service? The VA examiner is asked to discuss the Veteran's October 22, 1976 enlistment examination report, and the May 11, 1979 separation examination report. Specifically, the VA examiner must include discussion of whether the Veteran's puretone threshold results of 50 decibels at 3000 hertz at separation is reflected of aggravation of right ear hearing loss during service. The term "aggravated" means an increase in severity of the underlying disability that is not due to the natural progress of the disease. Any opinion expressed by the VA examiner must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Abdelbary, 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.