Citation Nr: 21077009 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 14-15 749 DATE: December 28, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and/or major depressive disorder (MDD), is remanded. REASONS FOR REMAND In February 2020, the Board remanded this claim for efforts to verify the Veteran's claimed stressor. Additionally, the Board directed the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for an examination to obtain a new nexus opinion. Following the remand, the relevant source for records, after requesting records from the Army Safety Center and the National Archives and Records Administration, informed VA it found no evidence to support documentation of the claimed stressor incident. A September 2021 examiner found on examination the Veteran did not meet the required criteria for a PTSD diagnosis, but did for moderate, recurrent MDD. The examiner rendered a negative opinion for direct service connection, stating it is unclear if MDD is related to service and stating so would be resorting to "mere speculation." The Board finds the September 2021 examiner's opinion inadequate to make an informed decision on the Veteran's claim. This examiner appears not to have engaged in review of the service treatment records (STRs) to find relevant treatment, diagnoses or reports and complaints of the Veteran. The post-active-service record is not discussed, nor are the lay statements of the Veteran and others. Moreover, this examiner conducted what appears to be a "telehealth" examination of the Veteran, but his opinion states it was in-person. Whether the examiner used the terms interchangeably, the above rationale for the opinion gives no indication of whether or not he questioned the Veteran about MDD. In short, the opinion's rationale is inadequate, as it explains nothing, does not address an alternative acquired psychiatric disorder to PTSD and does not comply substantially with the Board's February 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Further, the Secretary has a duty to ensure any medical opinion provided is adequate. 38 U.S.C. § 5103A (a); 38 C.F.R. § 3.159; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds by Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). Accordingly, the Board will again remand this claim for a medical opinion sufficiently responsive to its question and otherwise adequate for purposes of VA adjudication. The matter is REMANDED for the following action: 1. Contact the Veteran and/or his representative for information pertaining to any current treatment for psychiatric disorders, to include PTSD and/or MDD, at any VA facility and by any private treatment provider. Obtain any records of the above treatments not yet associated with the claims file and associate them with the claims file. The assistance of the Veteran and/or his representative should be requested in obtaining any records of recent treatment as indicated. All attempts to obtain records should be documented in the claims file. 2. After completing the development noted above, arrange for review of the claims file by an examiner, other than the VA examiner who produced the September 2021 opinion, with an appropriate specialty for producing findings for psychiatric disorders, to include PTSD and/or MDD. The complete electronic claims file must be made available to the examiner in conjunction with the review. The examiner should detail all findings. If the examiner deems a new examination to be necessary, arrange for that examination. The examiner is requested to render an opinion addressing the following: Whether it is at least as likely as not (a 50 percent or greater probability) acquired psychiatric disorder, to include PTSD and/or MDD, was incurred during active service or is caused by an event, injury or illness occurring in active service. If PTSD is diagnosed, the examiner should identify the stressor that forms the basis for this diagnosis. In rendering an opinion, the examiner should consider the Veteran's relevant lay statements of record, identified below, describing his claimed in-service stressor and the symptoms associated with his claimed acquired psychiatric disability. The examiner is requested to use in the opinion the exact language and terminology as stated above in the opinion question, as deviations from such language and terminology or the use of equivocal language such as "not related to" and similar phrases have been held on appeal to the Board's reviewing court to be an incorrect evidentiary standard for VA adjudication purposes. The opinion rendered by the examiner must be accompanied by a rationale, by which conclusions are supported by references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner is requested to comment on any relevant opinions found in the record. The examiner is further requested to discuss the Veteran's March 2013 and February 2014 Statements in Support of Claim, his June 2015 Decision Review Officer hearing testimony, his September 2015 correspondence, the January 2016 lay statement of the Veteran's daughter, M.C., and the March 2016 lay statement of D.G., as well as the Veteran's reports to treatment providers and VA examiners as they appear throughout the record. The Board urges the examiner to note that opinions rendered without discussing lay evidence of the Veteran as it pertains to the above claim will be deemed insufficient for VA adjudication purposes. L. S. Kyle Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.