Citation Nr: A21020240 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 190917-32125 DATE: December 17, 2021 REMANDED Service connection for left shoulder condition is remanded. Service connection for right shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2019 Appeals Modernization Act (AMA) rating decision. This rating decision denied entitlement to service connection for right and left shoulder disabilities. In September 2019, the Veteran appealed the decision by submitting a notice of disagreement (VA Form 10182). The Veteran selected to have his claim reviewed in the hearing lane. In September 2020, the Veteran testified at a hearing before a Veteran's Law Judge. No additional evidence was submitted during the 90-day window following this hearing. 1. Service connection for left shoulder condition is remanded. 2. Service connection for right shoulder condition is remanded. A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board finds there was a pre-decisional duty to assist error at the time of the June 2019 rating decision because the agency of original jurisdiction (AOJ) failed to obtain an adequate opinion addressing the claim of entitlement to service connection for bilateral shoulder disabilities. Here, a May 2019 VA examination was provided, and the examiner diagnosed right shoulder strain and left shoulder arthritis. As medical history, he reported the Veteran began experiencing pain and aching in his shoulders in 2000. The examiner observed the service treatment records documented a June 196[7] report of bilateral shoulder pain, but the next medical record documenting shoulder pain was from 2006. He opined the current shoulder disabilities were less likely than not causally related to the Veteran's active service there was no evidence of chronicity of care for almost 40 years after June 196[7]. The Veteran, however, has stated on multiple occasions that he has had pain since service in the shoulders. These competent lay statements were not considered by the examiner. Moreover, in September 2020, the Veteran testified that he experienced shoulder pain during active service and he sought treatment shortly after separating from active service. He continued to discuss the problem with private doctors over the years. He used over the counter medications and prescription medications over many years after separating from active service. He also described shoulder pain which continued every day. He noted his post service employment, as a bank teller and as a minister, were not physically demanding and his shoulder problems did not interfere with his employment. The Veteran is competent to report his experience of observable symptoms such as pain and his history of receiving medical care. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The May 2019 VA etiology opinion did not consider the Veteran's reports. Thus, it is not based on his complete medical history and it is not adequate to evaluate the claim. See Stefl, supra. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician. The examiner should review the entire claims file including the transcript of the September 2020 hearing before the Board. The examiner should opine whether the Veteran's right and left shoulder disabilities are at least as likely as not related to his active duty service including a June 1967 service treatment record documenting shoulder pain, his duties as military policeman, and/or using and training with shotguns and pistols. The examiner is advised that the Veteran is competent to report his observable symptoms such as pain and his history of receiving medical treatment (including self treatment.) The Veteran's contentions, as presented during the September 2020 hearing, must be specifically discussed and considered. If the examiner dismisses any such reports, a complete rationale for doing so must be provided. A complete rationale must be provided for any opinion expressed. If the clinician determines an additional examination is required to provide the opinions sought, schedule an examination. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.