Citation Nr: 21075147 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 15-10 885 DATE: December 17, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include paranoid schizophrenia is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Army from August 1980 to November 1980. The Veteran served during Peacetime. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. This case was previously before the Board in August 2021, when it was remanded to obtain outstanding VA and private treatment records, military personnel records, and a VA examination. The directives have been complied with and the matter has returned to the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran's claim for paranoid schizophrenia has been expanded as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a service connection claim for a diagnosed psychiatric disability encompasses all psychiatric disabilities shown by the record, however diagnosed). Entitlement to service connection for an acquired psychiatric disability, to include paranoid schizophrenia is remanded. The Veteran asserts entitlement to service connection for an acquired psychiatric disability, claimed as paranoid schizophrenia. Specifically, the he asserts that his schizophrenia began during service in October 1980. See August 2018 Fully Developed Claim. The Board notes that the appellant has active duty for training in the Army National Guard from August 11, 1980 to November 6, 1980. The Veteran's claim was last before the Board in September 2021, when it was remanded for additional development. First, the Board determined that the Veteran identified numerous private providers. Second, the Board found the need for confirmation of periods of ACDUTRA and INACDUTRA was necessary for proper adjudication of the Veteran's claim. 38 C.F.R. § § 3.6, 3.303 (2020). Finally, the Board determined that the Veteran was entitled to a VA examination to determine the manifestations of the Veteran's acquired psychiatric disability and any connection to the Veteran's service. In accordance with the September 2021 Board remand, the Veteran was afforded a VA examination in November 2020. The VA examiner noted a diagnosis of schizophrenia. The Veteran reported beginning to have problems in the last years of military service as well as being hospitalized. The Veteran further reported receiving Social Security disability insurance. The VA examiner reported psychiatric symptoms of suspiciousness, impairment of short- and long-term memory, speech intermittently illogical, obscure, or irrelevant, and impaired judgment. The VA examiner reported that the Veteran's schizophrenia results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Following an examination, the VA examiner opined that the Veteran's schizophrenia is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this opinion, the VA examiner reasoned that there is no evidence diagnosing the appellant with schizophrenia in-service, noting an October 1983 diagnosis. The Board finds this opinion to be inadequate as the basis for the rationale is the lack of a diagnosis in service. This rationale is inadequate as the absence of a diagnosis in service does not preclude service connection. Furthermore, the September 2021 Board remand directives specifically instructed that a medical opinion based solely on the absence of documentation in the record or that does not take into account the appellant's reports of symptoms and history is inadequate. Given these deficiencies, an addendum opinion is required with respect to the Veteran's service connection claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). As such a new opinion is needed prior to deciding the issue. The Veteran has also stated that he was hospitalized for schizophrenia during service. See November 2020 VA Examination Report. However, a review of the Veteran's claims file shows that no attempts have been made to associate any hospitalization records from that time period with the Veteran's claims file. Furthermore, during his November 2020 VA examination, the Veteran reported that he receives Social Security Disability Insurance (SSDI) due to his psychiatric disability. The Board finds that a remand for outstanding Social Security Administration (SSA) medical records is also warranted. The matters are REMANDED for the following action: 1. With any needed assistance from the Veteran, obtain and associate with the Veteran's electronic claims file any outstanding private or VA treatment records, specifically hospitalization records during the Veteran's service from August 11, 1980 to November 6, 1980. 2. Return the November 2020 examination report to the prior examiner, or a similarly situated examiner for addendum opinions. (If determined necessary, schedule the Veteran for VA examinations with examiner(s) of appropriate expertise to determine the nature and etiology of the acquired psychiatric disability). After reviewing the claims file and examining the appellant, the examiner should answer the following question: (a.) Is it as likely as not (a 50 percent probability or greater) that the appellant's acquired psychiatric disability, to include paranoid schizophrenia, was caused by the appellant's active service or periods of ACDUTRA? It should be noted that the appellant is competent to attest to observable symptomatology. The examiner's attention is invited to the appellant's statements concerning the onset of his claimed disability. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not take into account the appellant's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Following the completion of the directives outlined above, to the extent possible, readjudicate the claim. If any benefit sought on appeal remains denied, provide the appellant with a Supplemental Statement of the Case (SSOC). The SSOC should contain notice of all relevant actions taken on the claim, to include a summary of the evidence and applicable law and regulations considered pertinent to the issue. An appropriate period of time should be allowed for response before the case is returned to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. C. Slaughter, 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.