Citation Nr: 21072115 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 18-51 426 DATE: December 2, 2021 REMANDED Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a left foot condition is remanded. Entitlement to service connection for a gastrointestinal disorder, to include a choking condition, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1980 to July 1983. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In April 2020, the Board issued a decision denying service connection for PTSD, a left foot condition, and a gastrointestinal disorder. The Veteran appealed the matter to the Court of Appeals for Veterans Claims (Court), which partially vacated the April 2020 Board decision, pursuant to a June 2021 Joint Motion for Partial Remand (JMPR). The Court remanded the matter for action consistent with the terms of the JMPR. 1. Entitlement to service connection for PTSD is remanded. In the June 2021 JMPR, the parties agreed that the Board provided an inadequate statement of reasons or bases in the April 2020 denial of the claim for service connection for PTSD. Specifically, the parties noted inadequacies as to the development of the Veteran's claimed in-service stressors for PTSD. The Veteran has reported three stressors in support of his PTSD claim. First, he stated that while stationed in Germany in 1982, he was at a nightclub when it was bombed. Second, he stated that he witnessed a sexual assault and was threatened by the perpetrator to not disclose what he witnessed. Third, he stated that he was assaulted during basic training. The Veteran submitted stressor statements in May 2014. On February 18, 2015, the RO requested that the Veteran provide additional detail as to his stressors in order to seek assistance from the U.S. Army and Joint Services Records Research Center (JSRRC). The correspondence indicated that if the Veteran did not respond, VA would decide his claim after thirty days. On March 12, 2015, the Veteran submitted additional stressor statements, including the name of the nightclub he alleged that was bombed in 1982 in Germany and details regarding the sexual assault he witnessed. On March 19, 2015, less than thirty days after the February 18 letter, the VA issued a formal finding that there was a lack of required information to verify the Veteran's stressors and a rating decision was subsequently issued, denying the claim. However, this formal finding failed to address the Veteran's stressor statements submitted on March 12, 2015. The parties also cited to a New York Times article that discussed bombings at nightclubs in Germany in 1982. See Bombs Hit U.S. Bases in West Germany, N.Y. TIMES, June 2, 1982, https://www.nytimes.com/1982/06/02/world/bombs-hit-us-bases-in-west-germany.html. The parties agreed that upon remand, the Board must address the evidence outlined above in discussing whether VA satisfied its duty to assist regarding the verification of the Veteran's claimed in-service stressors. The Board finds that VA must further develop the Veteran's claim for entitlement to service connection for PTSD in light of the additional detail that he provided on March 12, 2015, which was not addressed in the March 19, 2015 formal finding. Any indicated development must also address the New York Times article noted by the parties in the JMPR. As the Board has determined that VA failed to satisfy its duty to assist in the verification of the Veteran's claimed in-service stressors, the matter must be remanded in order for such development to be performed. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). 2. Entitlement to service connection for a left foot condition is remanded. Regarding the Veteran's claim for service connection for a left foot condition, the parties agreed that the February 2015 VA examination of the left foot is inadequate for rating purposes. The Veteran's service treatment records reflect that he experienced left foot pain secondary to an injury in June 1981. See Feb. 2013 STR Medical, p. 10. However, in the negative nexus opinion provided, the examiner failed to address whether the Veteran's current foot condition could have been caused by his in-service left foot injury. The parties concluded that the Veteran must be provided a new medical opinion with adequate rationale addressing whether his current foot condition could have been caused by his in-service left foot injury. Accordingly, the matter must be remanded to afford the Veteran a new VA examination and opinion. See Stegall, supra. 3. Entitlement to service connection for a gastrointestinal disorder, to include a choking condition, is remanded. Regarding the Veteran's claim for service connection for a gastrointestinal disorder, the parties agreed that the January 2015 VA examination is inadequate for rating purposes. In the January 2015 examination, the Veteran reported that his gastrointestinal symptoms, including abdominal pain, four to five bowel movements a day of watery stool, and stomach and rectal burning after eating spicy foods, "have been present since basic training and continue to be present." The Veteran also reported diarrhea, nausea, and vomiting. The examiner issued medical opinions as to esophageal conditions and intestinal conditions. Neither opinion acknowledged the Veteran's statements that his conditions began in service and have continued since that time. Further, the examiner based the opinions solely on a lack of corroborating evidence in the medical records documenting the Veteran's symptoms. The parties concluded that the opinions are inadequate and that a new opinion must be obtained. Accordingly, the mater must be remanded to afford the Veteran a new VA examination and opinion. See Stegall, supra. The matters are REMANDED for the following action: 1. Conduct exhaustive development to attempt to verify the alleged stressors (as identified in the May 2014 statement and all March 2015 statements), to include his presence at a nightclub when it was bombed, witnessing a sexual assault, and experiencing assault during basic training. As to the nightclub bombings stressor, the New York Times article cited above (https://www.nytimes.com/1982/06/02/world/bombs-hit-us-bases-in-west-germany.html) must be considered. If necessary, the Veteran should be contacted to clarify the location, dates, and other details surrounding the facts of the stressor events, as well as to describe any stressors not listed above. Thereafter, perform any other indicated development as to the Veteran's claim for service connection for PTSD. 2. After completion of directive (1), schedule the Veteran for a VA examination to determine the nature and etiology of his left foot condition and gastrointestinal disorder. Any indicated evaluations, studies, or tests deemed necessary by the examiner should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion and the examination report should include a discussion of the Veteran's documented medical history and assertions. The examiner must address the following: (a.) Determine whether it is at least likely as not (a 50 percent probability or greater) that the Veteran's left foot condition is related to his active duty service. In so responding, the examiner must address all relevant lay and medical evidence of record, to include a June 1981 service treatment record indicating left foot pain secondary to an injury. See Feb. 2013 STR Medical, p. 10. (b.) Determine whether it is at least likely as not (a 50 percent probability or greater) that the Veteran's gastrointestinal disorder, to include a choking condition, is related to his active duty service. Upon examination, the examiner must elicit a complete and detailed history of the condition, including onset and symptomatology. The examiner must also address the Veteran's statements in the January 2015 VA examination in which he stated that symptoms "have been present since basic training and continue to be present." The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries and that his reports must be taken into account in formulating the requested opinions. The examiner must provide rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Watkins, 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.