Citation Nr: 21076875 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 15-26 225A DATE: December 28, 2021 REMANDED The issue of service connection for a right foot disorder is remanded. The issue of service connection for a right ankle disorder is remanded. The issue of service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served in the U.S. Marine Corps from June 1982 to June 1985. 1. The issue of service connection for a right foot disorder is remanded. 2. The issue of service connection for a right ankle disorder is remanded. 3. The issue of service connection for an acquired psychiatric disorder is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: In January 2019, the Board remanded the appeal to obtain authorization from the Veteran to obtain treatment records from a non-VA medical provider in Springfield Gardens in Queens, New York. The Veteran had previously provided authorization, but VA did not attempt to obtain the records. August 2020 and July 2021 letters to the Veteran requesting authorization were not clear. Remand is again necessary to attempt to obtain authorization to obtain the records. The record also indicates that the Veteran received mental health treatment at Highland Rivers CSB and at a Cobb County community health clinic. Treatment at these facilities was provided on a contractual basis through VA. Complete records must be obtained and associated with the file; notes indicating that the records are available in VistA are insufficient. The Veteran's service personnel records (SPRs) have not been associated with the file. They must be obtained. The record indicates that the Veteran is in receipt of Social Security Disability benefits. The evidence considered by the Social Security Administration (SSA) in granting the Veteran's claim is not of record but must be obtained. See Masors v. Derwinski, 2 Vet. App. 181, 187-188 (1992). In an October 2011 Statement in Support of Claim for Posttraumatic Stress Disorder (PTSD), the Veteran reported a stressor that occurred in the Philippines. The Veteran stated that he did not remember the date of the event but that it was during the time when he was deployed. In a February 2012 memorandum, the RO determined that there was not sufficient information to contact the Joint Services Records Research Center (JSRRC) to attempt to verify the stressor. In an April 2021 letter, the RO informed the Veteran that he must provide a 60-day period of when the reported event occurred so that they could attempt to verify the stressor. The Veteran did not respond and the RO did not attempt to verify the stressor. The Court of Appeals for Veterans Claims has held that in similar circumstances, where VA is aware of the period of deployment, and no 60-day period is provided by the claimant, the RO must submit multiple requests covering the entire period, if necessary, to attempt to verify the stressor. See Gagne v. McDonald, 27 Vet. App. 397 (2015). Therefore, remand is necessary to attempt to verify the reported stressor. The Veteran has reported several other in-service stressors that the RO must also attempt to verify. Records added to the file in November 2021 indicate that the RO is attempting to obtain additional records. As those records may be relevant to this appeal, remand is necessary. Remand is necessary to obtain a new VA medical opinion as to the Veteran's acquired psychiatric disorders, if service connection cannot be granted following verification of his reported stressors. Remand of the issues of service connection for a right ankle and right foot disorder is necessary to obtain new VA examinations to determine exactly what disorders the Veteran currently has and whether they were caused by service. He was last provided an examination more than 10 years ago and VA treatment records are not clear as to the diagnosed disorders. 2. Request that the Veteran provide authorization to obtain records from Springfield Gardens in Queens, New York. The Veteran is informed that previous authorizations to obtain records from this facility have expired and, therefore, new authorization must be provided for VA to attempt to obtain the records. VA apologizes for not attempting to obtain the records when authorization was previously provided. 3. Obtain and associate with the file all treatment records from Highland Rivers CSB and from the Cobb County community health clinic where the Veteran was provided mental health treatment on a contractual basis from VA. 4. Obtain and associate with the record all the Veteran's SPRs. 5. Contact the SSA and request that it provide documentation of the Veteran's determination of disability benefits and copies of all records developed in association with the decision. 6. Take all appropriate steps to verify each of the Veteran's reported in-service stressors, including his reported stressor that occurred while he was in the Philippines. If a 60-day period is required for a request of verification, multiple requests must be submitted, if necessary. 7. AFTER COMPLETION OF THE DEVELOPMENT IN STEPS 2 TO 6, AND ONLY IF NECESSARY, return the file to the VA examiner who conducted the March 2021 VA PTSD examination. If the examiner is not available, have the file reviewed by a similarly qualified examiner. If necessary to respond to the inquiries below, schedule the Veteran for a VA examination to obtain an opinion as to the nature and etiology of all identified acquired psychiatric disorders. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address whether each identified acquired psychiatric disorder was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. IN ADDITION TO ANY RECORDS ADDED TO THE FILE AS A RESULT OF THE ABOVE-DIRECTED DEVELOPMENT, the examiner's attention is drawn to the following: *May, June, July, and August 1984 service treatment records (STRs) indicating treatment for psychiatric symptoms; diagnoses of rule out depression and suicidal ideation, and alcoholism; and hospital admission for alcohol abuse. VBMS Entry 3/1/2014, p. 33, 35, 58, 59, 61. *May 1985 report of medical history at service separation in which the Veteran indicated he had a head injury. VBMS Entry 3/1/2014, p. 24. *May 1985 physical examination for service separation on which the Veteran was normal as to any psychiatric symptoms. VBMS Entry 3/1/2014, p. 17-18. *October 1985 private treatment records indicating hospitalization for psychiatric symptoms and a diagnosis of atypical psychosis. VBMS Entry 12/27/2012. *June 2011 claim on which the Veteran reported that his alcoholism began in service. *June 2011 Report of General Information on which the Veteran reported that he had PTSD. *June 2011 Authorization for Release of Information on which the Veteran described in service stressors. *July 2011 VA treatment record providing the history of the Veteran's alcohol use and psychiatric symptoms and treatment. He was diagnosed with alcohol dependence and rule out personality disorder NOS with cluster B features. VBMS Entry 8/4/2011, p. 1. *August 2011 VA treatment record stating that the Veteran had "PTSD from several traumatic events in his life including military service" and stating that he had been self-medicating with tobacco and alcohol. VBMS Entry 10/5/2011, p. 15. *August 2011 VA treatment record stating that the Veteran most likely had PTSD and that his alcohol use was more likely self-medicating rather than primary alcoholism. VBMS Entry 1/15/2013, p. 97. *September 2011 VA treatment records in which the Veteran reported that he drank alcohol to control his anxiety, that he started drinking alcohol while in service, and stating diagnoses of anxiety disorder NOS, alcohol dependence, and personality disorder NOS with cluster B traits. VBMS Entry 10/5/2011, p. 2-6. *September 2011 VA mental health diagnostic study stating that the Veteran's alcohol use began while in service. VBMS Entry 1/15/2013, p. 88. *October 2011 Statement in Support of Claim for PTSD in which the Veteran described an in-service stressor that occurred while he was in the Philippines, and on which he reported many negative changes following the incident. *October 2011 Correspondence in which the Veteran described several in-service stressors, as well as his post-service mental health symptoms and treatment. *March 2012 VA examination report stating that the Veteran had alcohol dependence and borderline personality disorder. *May 2013 VA mental health evaluation stating that the Veteran reported that he was anxious and depressed at service separation and possibly since he entered service; the Veteran described several in service stressors; the Veteran stated that he began drinking alcohol at age 18 and continued since that time, with his longest period of sobriety being 6 to 7 months beginning in September 2009; and stating diagnoses of anxiety disorder NOS, mood disorder NOS, rule out substance-induced anxiety and mood disorder, continuous alcohol dependence, cocaine dependence in full remission, and nicotine dependence. VBMS Entry 4/30/2014, p. 39-45. *May 2013 VA treatment record stating that the Veteran had attempted suicide in 1985 after separating from service. VBMS Entry 4/30/2014, p. 47. *December 2013 VA treatment record stating diagnoses of depressive disorder NOS, PTSD, and substance and alcohol abuse. VBMS Entry 4/30/2014, p. 19. *January 2014 notice of disagreement (NOD) in which the Veteran asserted that his psychiatric disorders began in service. *October 2016 VA treatment record in which the Veteran described several in-service stressors. VBMS Entry 11/28/2018, p. 105. *October 2016 VA treatment record stating a diagnosis of major depressive disorder. VBMS Entry 11/28/2018, p. 1. *December 2016 VA treatment record stating that the Veteran was being treated for PTSD and taking medication, in which he described several in service stressors, and in which the VA psychologist stated that the PTSD was service connected. VBMS Entry 11/28/2018, p. 69, 71. *June 2017 VA treatment record stating a diagnosis of chronic PTSD. VBMS Entry 11/28/2018, p. 4. *July 2018 VA treatment record stating a history of PTSD and depression, and a "personal history" of a traumatic brain injury. VBMS Entry 9/18/2020, p. 16. *October 2018 VA treatment record stating that the Veteran had PTSD caused by exposure to actual or threatened death, serious injury, or sexual violence. VBMS Entry 9/18/2020, p. 100. *September 2020 VA treatment record stating a diagnosis of chronic PTSD, and in which the Veteran described his reported in-service stressors. VBMS Entry 9/18/2020, p. 1, 5. *March 2021 VA examination and medical opinion stating that the Veteran had PTSD, depressive disorder, and alcohol use disorder; that his symptoms could not be separated due to the overlapping nature of his disorders; and that PTSD was caused by the Veteran's exposure to a death threat while in service in the Philippines. 8. AFTER COMPLETION OF THE DEVELOPMENT IN STEPS 2 TO 6, schedule the Veteran for VA foot and ankle examinations to obtain an opinion as to the nature and etiology of each identified right foot and ankle disorder. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Identify each right foot and right ankle disorder which the Veteran currently has or has had at any time since he first filed his claim of service connection in June 2011. (b.) Whether each identified right foot disorder was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (c.) Whether each identified right ankle disorder was caused by any in-service event, injury, disease, or disorder, or in any way originated during service. IN ADDITION TO ANY RECORDS ADDED TO THE FILE A RESULT OF THE ABOVE-DIRECTED DEVELOPMENT, the examiner's attention is drawn to the following: *November 1982 STR stating that the Veteran injured his right ankle while playing basketball and stating a diagnosis of rule out second-degree sprain and possible calcium build up. VBMS Entry 3/1/2014, p. 50. *STR stating that the Veteran had pain on the bottom of his right foot and stating a diagnosis of a possible sliver or infection. VBMS Entry 3/1/2014, p. 31. *May 1985 report of medical history at service separation where the Veteran did not report any foot or ankle symptoms, and his physical examination for service separation on which his feet and lower extremities were normal. VBMS Entry 3/1/2014, p. 17, 18, 24, 26. *June 2011 VA claim on which the Veteran reported that he had a right ankle disorder and right foot ankylosis and tendonitis which all began in 1983 while in service at Camp Pendleton, California. *June 2011 Authorization for Release of Information where the Veteran reported being forced to do a training run while in service with a sprained ankle, and that his right ankle and foot symptoms had continued since that time. *November 2011 VA ankle and foot examination reports stating diagnoses of right ankle tendonitis, plantar calcaneal spur, and enthesophyte at the Achilles' tendon on the calcaneus; and right foot tendonitis, plantar calcaneal spur, and arthritis. *January 2015 VA treatment record in which it was noted that the Veteran was forced to participate in a training run in service when he had an injured ankle. VBMS Entry 11/28/2018, p. 107. THE VETERAN IS ADVISED that any failure on his part to cooperate fully with VA's development of this matter will only result in adjudication being further delayed or the possible denial of his claims. Under the law, While VA has a duty to assist the veteran in substantiating his claim, that duty is not a one- way street. Woods v. Gober, 14 Vet.App. 214 (2000); see also Hurd v. West, 13 Vet.App. 449 (2000) (the Veteran cannot passively wait for help from VA). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. E. Miller, Counsel The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.