Citation Nr: 21065290
Decision Date: 10/25/21	Archive Date: 10/25/21

DOCKET NO. 17-50 428A
DATE: October 25, 2021

REMANDED

Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD), depression, and bipolar disorder, is remanded.

REASONS FOR REMAND

The Veteran had active service from March 1979 to June 1979, with additional service in the National Guard.

This case comes before the Board of Veterans' Appeals (Board) on appeal of a June 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia.

As an initial matter, the Board has recharacterized the Veteran's claim pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) to include service connection for any acquired psychiatric disorder. 

The Board has reviewed the evidence presently of record and observes that there are VA outpatient treatment records indicating that the Veteran may have multiple mental health diagnoses. For example, a June 2015 VA nursing triage record noted a positive PTSD screen. A November 2013 VA mental health contract noted the Veteran continues to struggle with bipolar symptoms. An October 2013 medication reconciliation record noted medication prescribed for depression. In a May 2012 lay statement, the Veteran reported that after multiple Article 15 punishments, he began to experience episodes of anger and blackouts during and immediately after separation from active service. Additional development is necessary before the Board can adjudicate these claims for service connection. The Board notes that the Veteran has not been afforded a VA examination to evaluate the nature and etiology of his claimed acquired mental disorders to include bipolar disorder, depression, and PTSD. This should be corrected on remand.

In addition, an April 2013 VA neuropsychology record notes the Veteran has reportedly applied for Social Security Administration (SSA) disability benefits based on his mental health symptoms. Following a thorough review of the claims file, the Board is unable to identify any records from the SSA. When VA has notice that the Veteran may be receiving disability benefits from the SSA, and that records from that agency may be relevant, VA has a duty to acquire a copy of the decision granting SSA disability benefits, and the supporting medical documents on which the decision was based. 38 C.F.R. § 3.159(c)(2). However, VA need only obtain "relevant" SSA disability records, which, under 38 U.S.C. § 5103A, are those records that relate to the injury for which the appellant is seeking benefits and have a reasonable possibility of helping to substantiate the claim. Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010).

The matters are REMANDED for the following action:

1. Contact the Social Security Administration (SSA) and request they provide VA with the Veteran's complete SSA records, including any administrative decision(s) on his application for SSA disability benefits and all underlying medical records. A copy of any records obtained from SSA, to include a negative reply, should be included in the Veteran's record.

2. After completing the above and any other indicated development, schedule the Veteran a VA mental health examination with a psychologist or psychiatrist who has reviewed the claims file in its entirety. This examiner must ascertain any current psychiatric disorders. For each diagnosed psychiatric disorder, the examiner must render an opinion as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that such disorder is related to service.

All opinions must be supported by a complete rationale.

 

 

A. C. MACKENZIE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	B. Banks, 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.