Citation Nr: A21020547 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 190124-2623 DATE: December 27, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1972 until his honorable discharge in October 1975. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.902(c). A rating decision was issued under the legacy system in February 2018. In September 2018, the appellant opted into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a Rapid Appeals Modernization Program (RAMP) election form and selecting the higher-level review option. The Regional Office issued an AMA rating decision pursuant to RAMP in December 2018, which is the decision on appeal. In the VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), the appellant elected the Hearing option; therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the appellant or their representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). In October 2019, the Veteran testified before the undersigned at a hearing via videoconference. A transcript of his testimony has been associated with the claims file. Entitlement to service connection for posttraumatic stress disorder (PTSD). Unfortunately, the claim must be remanded to attempt to verify the in-service PTST stressors and for an examination. The Board's jurisdiction in AMA cases is limited to correcting predecisional duty to assist errors. 38 C.F.R. § 20.802. In this case, the Regional Office failed to attempt to verify the Veteran's stressors and to provide him with a VA examination prior to the decision on appeal. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. This includes attempting to verify his in-service stressors. VA denied his claim without conducting a search by contacting the appropriate records department. In Gagne v. McDonald, 27 Vet. App. 397 (2015), the Court held that VA's duty to assist is not bound by a 60-day limitation imposed by the service department for stressor verification requests. The Court found that VA was obligated under its duty to assist to submit multiple 60-day requests to the unit for records of a stressor event. Id. at 404. The Veteran's MOS was infantryman on his DD-214. He provided statements regarding his in-service stressors explaining that he was involved in a helicopter crash in Washington and a vehicle crash in Germany. His testimony repeated these assertions. His stressors are as follow: in the first half of 1973 while stationed at Fort Lewis in Washington, the helicopter he was in was damaged during a firing exercise and could not land normally. He reported having to aid in the landing and then drank to intoxication afterward. He also reported having to see a psychologist to be cleared to fly again. His second stressor occurred in mid-1975 while stationed in Germany when the APC in front of him crashed. He reported seeing two serious injuries in the aftermath of the crash. He also reported having nightmares afterward and attempted to repress the memory of the event. See August 2017 Private Treatment Record. His military personnel records confirm he was stationed in Washington in 1973 and in Germany from August 1974 to October 1975 as an "[armored personnel carrier] APC driver." See August 2017 Private Medical Record, Service Treatment Records, and Military Personnel Records. The Veteran's MOS and personnel records support his testimony and statements about his in-service stressors. Due to the specificity provided be the Veteran, VA had a duty to attempt to verify his stressors. VA's duty to assist also includes providing a medical examination when one is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Regional Office did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, has a presumptive disease during the pertinent presumptive period, or is service-connected for a disability that may have caused or aggravated the Veteran's disability; and (3) indicates that the claimed disability may be associated with the in-service event, injury, disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). The Veteran asserts that he developed PTSD as a result of his military service where he was a part of and witnessed a helicopter crash landing and when he witnessed the crash and injuring of service members during a drill in Germany. See October 2019 Hearing Transcript. The Veteran has a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis for PTSD. See January 2018 VA Treatment Note. A private treatment psychologist also diagnosed him with PTSD but used the DSM-IV. A diagnosis alone is not enough to grant a claim for service connection. A nexus and verification of the stressors are also required. He first sought treatment for suicidal ideation and mental health in May 2017. He reported at that time that his depressive symptoms began one year prior when he was fired from his job. See May 2017 VA Treatment Note. He also denied PTSD symptoms at that time and had already begun therapy. He reported worrying about finances and his health. This was not deemed to be clinical in nature. He has a history of substance use and ADHD. The Veteran testified that after he first sought treatment for his mental health, he was informed that he had PTSD from in-service stressors. He had used cannibis and alcohol during and since service. Three months prior to his January 2018 diagnosis of PTSD a VA treatment provider found as follows: "Veteran's symptoms do not meet diagnostic criteria for PTSD but he does experiencing residual trauma-related symptoms including severe thought and emotional avoidance. Provider encouraged Veteran to engage in Cognitive Processing Therapy to help him process his traumatic experiences. Provider offered rationale and encouragement. Veteran plans to consider this over the next week and make a decision during session next week." See November 2017 VA Treatment Records. He was then diagnosed with PTSD. This statement by a treating psychologist prior to the decision on appeal required VA to obtain a VA examination. As such, the claim is remanded for further development. The matters are REMANDED for the following action: 1. Contact the appropriate service department for verification of the Veteran's reported stressor incidents involving a helicopter in 1973 and the 1975 APC crash in Germany. If the appropriate service department is only able to conduct a search for a 60-day time period, then separate inquiries of that length should be made to cover the entire period of the possible stressor identified by the Veteran. 2. After the first directive has been completed, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's acquired psychiatric disabilities, to include PTSD. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion as to the following: (a.) Whether the Veteran has a current diagnosis of posttraumatic stress disorder (PTSD) in accordance with the DSM-5 standards. If the examiner determines that PTSD is present, then they must specify the stressors supporting that diagnosis. (b.) Whether the Veteran has a diagnosis of any acquired psychiatric disabilities (other than PTSD) that have been present at any time during the pendency of this appeal, even if such conditions have since resolved. In doing so, the examiner's attention is directed to the various diagnoses reflected in the Veteran's post-service medical records. (c.) For each identified psychiatric disability, whether it is at least as likely as not (50 percent probability or more) that the Veteran's acquired psychiatric disability had its onset in or is otherwise etiologically related to his active military service. In rending their opinions, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) The Veteran's August 2017 private treatment report by Dr. R.O. and the accompanying statements regarding his in-service stressors. (b.) The Veteran's October 2019 Board hearing testimony. (c.) The VA treatment records referenced above diagnosing him with PTSD. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that they have exhausted the limits of current medical knowledge in providing an answer to the particular question(s). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Johnston, 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.