Citation Nr: 21068667
Decision Date: 11/12/21	Archive Date: 11/12/21

DOCKET NO. 19-23 459
DATE:       November 12, 2021

REMANDED

Entitlement to service connection for major depressive disorder is remanded.

REASONS FOR REMAND

The Veteran served on active duty from December 1960 to September 1963.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision of a Department of Veteran Affairs (VA) regional office (RO). In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge; a transcript of the hearing is of record.

Although the Board regrets the additional delay, a remand is necessary to ensure there is a complete record on which to decide the appellant's claim.

The Veteran contends that his major depressive disorder is related to incidents that occurred during boot camp and that his symptoms manifested while he was on active duty. See February 15, 2017 VA 21-526EZ, Fully Developed Claim. VA treatment records show the Veteran was diagnosed with anxiety and mild depression and currently receives mental health treatment. See August 1, 2019 CAPRI. However, no examiner has opined whether the diagnosis may be related to his active service.

Also, review of the claims file indicates there may be relevant outstanding VA treatment records. The Veteran asserted that he has been seen in the VA medical system since 1996. See April 30, 2016 VA 21-526EZ, Fully Developed Claim. However, in a statement in support of an earlier claim, he stated that he started receiving treatment in the VA system in 2001 or 2002. See November 22, 2010 VA 21-4138 Statement in Support of Claim. A medical treatment record showed the Veteran went to a VA medical center in 2002 to establish care with the VA and a primary care provider. See May 11, 2010 Medical Treatment Record-Government Facility. The Agency of Original Jurisdiction did not confirm that the Veteran was not enrolled in VA healthcare prior to 2002. The AOJ should do so and obtain records of any such care on remand. Moreover, any outstanding VA treatment records from September 2019 to the present should be associated with the claims file.  See Bell v. Derwinski, 2 Vet. App. 611 (1992).

As no examiner has opined whether the Veteran's diagnosis may be related to his active service and relevant outstanding VA medical treatment records may exist, a remand is warranted.

The matter is REMANDED for the following action:

1. Obtain and associate outstanding VA treatment records from 1996 to 2002 and from September 2019 to the present with the Veteran's claims file. If no records are available for the period from 1996 to 2002, the AOJ should memorialize the steps taken to locate any extant records.

2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's major depressive disorder. The claims file should be reviewed, and the examiner should offer an opinion on the following:

(a.) Is it as least likely as not (50 percent probability or greater) that the Veteran's major depressive disorder arose during active duty or is otherwise related to his active service?

In offering the opinion, the examiner is asked to consider and discuss all pertinent evidence in the claims file, to include the appellant's lay statements regarding the history of his symptoms and the incidents that occurred during boot camp. A thorough and complete rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings.

 

 

J. B. FREEMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C.L. Hamilton, 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.