Citation Nr: 21076983
Decision Date: 12/28/21	Archive Date: 12/28/21

DOCKET NO. 17-02 895
DATE: December 28, 2021

REMANDED

Entitlement to service connection for a psychiatric disorder is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Navy from February 1967 to March 1970, including foreign service in the Republic of Vietnam.  For his meritorious service, the Veteran was awarded (among other decorations) the Vietnam Service Medal and Vietnam Campaign Medal.

He testified during a June 2021 virtual hearing.  A transcript of this proceeding has been associated with the record.  During this hearing, the presiding Veterans Law Judge (VLJ) noted that the Veteran's service personnel records (SPRs) showed clear and convincing evidence of combat, as it relates to any pending posttraumatic stress disorder (PTSD) claim.

Upon the evidence of record, this appeal has been expanded to include all acquired psychiatric disorders.  Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).

Although the Board sincerely regrets the additional delay this will cause, further development is required prior to the adjudication of this appeal.

First, the Veteran has reported psychiatric treatment at two separate Vet Centers; a complete copy of these records have not yet been obtained.  Remand is required for this purpose. 

Further, the Veteran underwent VA psychiatric examinations in May 2015 and March 2016.  These evaluations are inadequate, as the examiners declined to offer a current diagnosis despite competent evidence of such in the record.  See, e.g., Vet Center and VA treatment records (showing treatment for PTSD).  Accordingly, a new examination is needed.  

The matter is REMANDED for the following action:

1. With any necessary assistance from the Veteran, obtain a complete copy of his medical records relating to treatment at multiple Vet Centers, including in Wisconsin (La Crosse) and Minnesota.  

2. Obtain an addendum opinion addressing the questions below.  If the examiner determines that an opinion may not be offered without first examining the Veteran, an examination shall be scheduled.

The claims file and a copy of this remand must be made available for review.  

In particular, the examiner is asked to offer medical opinions as to:

(a) Identify all psychiatric disorders shown by the Veteran during the period on appeal, to include PTSD.  A diagnosis of PTSD must be offered in accordance with VA regulations.

In doing so, the examiner must account for the various diagnoses of PTSD throughout the record, and the Veteran's competent reports of psychiatric symptoms during the period on appeal.

(b) For EACH diagnosis, opine whether it is at least as likely as not that the condition began in service, was caused by service, or is otherwise related to service, including exposure to combat?

(c) For EACH diagnosis, opine whether it is at least as likely as not that the condition was caused or aggravated by any of the Veteran's service-connected disabilities (including the stress caused thereby) or the treatment thereof?

Here, the examiner must consider the lay testimony of record regarding a link between the Veteran's physical disabilities and his mental symptoms.

A complete rationale should be provided for all opinions or conclusions expressed.  The Veteran is competent to attest to observable symptomatology.  If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

 

 

Evan M. Deichert

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	K. Kovarovic, 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.