Citation Nr: 21065753 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 20-07 552 DATE: October 27, 2021 ORDER The Board of Veterans' Appeals' (Board) March 2021 decision denying service connection for posttraumatic stress disorder (PTSD) is vacated. REMANDED Entitlement to service connection for PTSD is remanded. FINDING OF FACT At the time of the March 2021 Board decision, there were outstanding medical evidence that had been received but was not associated with the file or reviewed prior to the Board's decision. CONCLUSION OF LAW Vacatur of the Board's March 2021 decision denying entitlement to service connection for PTSD is warranted. 38 U.S.C. §§ 7103(c), 7104(a); 38 C.F.R. § 20.904. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from March 1955 to May 1976. 1. The Board of Veterans' Appeals' (Board) June 2021 decision denying service connection for posttraumatic stress disorder (PTSD) is vacated The Board of Veterans' Appeals (Board) may vacate an appellate decision at any time upon request of the appellant or representative, or on the Board's own motion, when an appellant has been denied due process of law. 38 U.S.C. § 7104(a); 38 C.F.R. § 20.904. In this case, the Veteran submitted evidence to the Board, which was received in February 2021 but, due to processing delays, was not uploaded to the case file until after the March 2021 issuance of the Board's last decision regarding the Veteran's claim noted herein. As this evidence was not addressed by the March 2021 Board decision and is pertinent to the issue at hand, the Appellant's due process rights would be violated if the prior decision were allowed to stand. Accordingly, the Board grants the Appellant's motion to vacate the March 2021 decision, regarding the denial of the Veteran's claim for service connection for PTSD. With regards to the Veteran's claim for increased rating for a heart condition, which was remanded in that same March 2021, that claim shall not be disturbed as such claim was remanded, and the additional evidence was not related to that claim. REASONS FOR REMAND 1. Entitlement to service connection for PTSD is remanded. In April 2018, the Veteran was provided with a VA psychiatric examination to assess the nature and etiology of any diagnosed psychiatric disability. The April 2018 VA examiner ultimately concluded that the Veteran did not current suffer from any diagnosable psychiatric disability during the claims period. Specifically, the examiner noted that the Veteran did not fulfill the criteria under the DSM-5 for a diagnosis of PTSD. To this end, the examiner did note that the Veteran had a history of alcohol abuse and depression, however, noted that these conditions had resolved, and were no longer a clinically diagnosable. In February 2021, the Veteran, through his representative, submitted a private psychiatric evaluation completed by a private medical professional. The evaluation form not only noted a clear and explicit diagnosis for PTSD, but also links such condition to the Veteran's active service period, to include his service in Vietnam. The Board, however, find that considering the additional medical evidence that has been submitted by the Veteran, the previous April 2018 VA examination opinion is rendered inadequate, and remand is required for an addendum opinion considering the full record, to include the newly submitted private findings. The Board notes that the VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). The Board also has considered the positive private opinion submitted by the Veteran but find that such opinion to be also inadequate and incomplete. To this end, the Board finds that the examiner failed to address other evidence of record, to include namely the previous VA examination and finding, or the lack of any positive diagnosis for PTSD or psychiatric condition contemporaneous to the claims period. The Board finds that lack of rationale regarding such findings, or lack of findings, to render the opinion also inadequate and incomplete, and requires further development, to specifically include the examination and opinion addressing the totality of the record. As such, as such development for this claim is incomplete, the Board must remand this claim for the VA to fulfill its duty to the Veteran. The matters are REMANDED for the following action: 1. Obtain all VA medical records of treatment to include any hospitalizations. 2. Then, schedule the Veteran for a VA mental disorders examination with a psychiatrist or a psychologist who has not already examined him. The examiner must review the claims file and should note that review in the report. All indicated studies deemed necessary by the examiner should be performed, and all findings should be reported in detail. All opinions must be accompanied by a rationale. The examiner must consider the Veteran's lay statements regarding the incurrence of the disabilities and continuity of symptomatology since service. The examiner should provide the following information: (a) Provide a full multiaxial diagnosis. Any indicated psychiatric testing necessary to support the diagnosis should be conducted. Specifically, state whether each criterion for a diagnosis of PTSD is met. The examiner is advised that VA has already conceded fear of hostile military or terrorist activity during his service. (b) If a diagnosis of PTSD is appropriate, comment upon the link between the current symptomatology and any in-service stressor reported by the Veteran and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) related to active service, a stressor during service, or the fear of hostile military or terrorist activity during service. (c) With regard to each diagnosed psychiatric disability, provide an opinion whether it is at least as likely as not (50 percent or greater probability) that each psychiatric disability is related to active service or any event of service. (d) For each diagnosed psychiatric disability, provide an opinion whether it is at least as likely as not (50 percent or greater probability) that each disability was caused by the service-connected disabilities. (e) For each diagnosed psychiatric disability, provide an opinion whether it is at least as likely as not (50 percent or greater probability) that each psychiatric disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by the service-connected disabilities. (Continued on the next page) The examiner must reconcile any findings with those opinion and medical evidence already of record, and must explicitly state consideration of such. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ziheng Zhu, 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.