Citation Nr: 21067321 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 13-19 327 DATE: November 3, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, is remanded. REASONS FOR REMAND The Veteran served in the Army Reserve from January 1988 to June 1993, including active duty for training (ACDUTRA) from July 1988 to October 1988, among others. This matter comes before the Board of Veterans' Appeals (Board) from the January 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The appeal was previously remanded in January 2017, August 2018, and December 2020 for additional development. The claim has since been returned to the Board for further appellate review. 1. Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, is remanded. The Board regrets the delay, however additional development is required prior to adjudicating the claim for an acquired psychiatric disorder, to include schizophrenia. First for all issues, remand is necessary to verify all periods of ACDUTRA and INACDUTRA. In the prior December 2020 remand, the Board noted that the AOJ only requested Defense Finance and Accounting Service (DFAS) from July 1988 to October 1988, which are the dates the Veteran served on ACDUTRA. However, the Veteran's service personnel records reflect he was discharged in June 1993. Therefore, the Board requested that attempts be made to obtain the Veteran's records from all appropriate sources, to include a request of pay records from the Defense Finance and Accounting Service (DFAS). The Board asked that the RO to verify the exact dates of any Army Reserve ACDUTRA or INACDUTRA from January 1988 through December 1993. On remand, additional Defense Finance and Accounting Service (DFAS) leave and earning statements were obtained that provided greater insight as to the Veteran's periods of ACDUTRA and INACDUTRA; but these additional records do not specify the EXACT dates of ACDUTRA and INACDUTRA for the entirety of his service. Therefore, on remand the RO must expressly indicate the dates of ACDUTRA and INACDUTRA. Also, the Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In the December 2020 remand the Board directed the RO to secure an adequate VA examination and opinion. The examiner was instructed to provide an etiology opinion with respect to whether the Veteran's current acquired psychiatric disability was the result of a disease or injury incurred during a period of ACDUTRA or an injury during INACDUTRA. Moreover, the examiner was instructed to provide a complete rationale for all opinions and a discussion of the facts and medical principles involved. The Veteran received a July 2021 VA examination. The examiner noted a diagnosis of schizophrenia. The examiner provided a positive nexus opinion. The examiner reasoned "only if the Veteran's statements alone can be trusted he says he began to have Schizophrenic symptoms in the military and he raised his concerns in sick call at Ft. Leonard Wood." The July 2021 examiner provided an addendum opinion in August 2021. The examiner noted the Veteran's claim file was not reviewed. The examiner stated, "to be perfectly clear this Examiner has never said that there is documentation in the Veteran's SMR of his mental illness." The examiner explained that in fact the Veteran stated he raised mental health concerns while in the military; however, there are no SMR records substantiating the Veteran's statements. Therefore, the examiner concluded there is no documented record to link to the diagnosed schizophrenia to military service. The examiner failed to opine, in either examination report, on whether the Veteran's schizophrenia was the result of a disease or injury incurred during a period of ACDUTRA or an injury during INACDUTRA. Next, the rationale provided in the July 2021 examination was conclusory and therefore inadequate. The examiner's rationale lacked supporting medical evidence or facts. The Board notes that the August 2021 addendum opinion did not consist of an opinion or supporting rationale. Therefore, there is no adequate medical opinion of record upon which the Board can rely to decide the claim. For the foregoing reasons and in light of these arguments and deficiencies, the Board finds remand is warranted. The matters are REMANDED for the following action: 1. Verify all periods of ACDUTRA and INACDUTRA in a memorandum for the claims file that EXPRESSLY indicates the dates of ACDUTRA and INACDUTRA from January 1988 through December 1993 from all appropriate sources. If such information is not available, or the search for any such information otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and likely cause of the Veteran's acquired psychiatric disability, to include schizophrenia. The Veteran's entire claims file, to include a copy of this remand, should be provided to the examiner. Following a complete review of the record and examination of the Veteran, the examiner should identify all acquired psychiatric disabilities present. For each identified acquired psychiatric disability, provide an opinion with respect to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's current acquired psychiatric disability was the result of a disease or injury incurred during ACDUTRA, or an injury incurred during a period of INACDUTRA. The examiner should discuss the Veteran's reported history during his service with the Army Reserve and, if appropriate, the examiner should identify the specific event or events that led to his psychiatric condition. In addressing the above, the examiner must consider and discuss all pertinent medical and lay evidence of record, to include competent, lay assertions as to the nature, onset, and continuity of symptoms. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If lay assertions in any regard are discounted, the examiner should clearly state, and explain why. The examiner should not discount the Veteran's lay statements or rely on an absence of medical evidence in the record to support his or her conclusions. All opinions must include a detailed rationale. Providing an opinion or conclusion without explanation will delay processing of the claim and require further clarification. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Braxton, 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.