Citation Nr: 21005578 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 17-10 998 DATE: February 2, 2021 REMANDED Entitlement to service connection for an immune system disorder is REMANDED. Entitlement to service connection for gastroenteritis is REMANDED. Entitlement to service connection for ulcerative colitis is REMANDED. Entitlement for service connection for total colectomy, to include as secondary to a gastrointestinal disorder, is REMANDED. Entitlement to service connection for multiple intestinal blockage is REMANDED. Entitlement to service connection for bilateral hip arthritis, to include as secondary to an immune system disorder, is REMANDED. Entitlement to service connection for right hip replacement is REMANDED. REASONS FOR REMAND The Veteran served honorably in the United States Army from September 1961 to August 1964. Entitlement to service connection for immune system, gastroenteritis, ulcerative colitis, total colectomy, multiple intestinal blockage, bilateral hip arthritis, and right hip replacement disabilities is remanded. In February 2019, the Board addressed the Veteran’s claims listed on the title page. At that time, the Board remanded the Veteran’s claims to associate additional medical records with the record and schedule VA examinations that addressed the nature and etiology of the claimed disabilities. Importantly, the Board specifically directed the agency of original jurisdiction (AOJ) to “(a)ssist the Veteran by contacting the relevant authority with possession of records at Miners Hospital in Frostburg, Maryland. If the RO cannot locate such records, it must specifically document the attempts that were made to locate them and explain in writing why further attempts to locate or obtain any government records would be futile.” In November 2019, a Report of Contact was associated with the claims file. Therein, the AOJ confirmed the contact information for Western Maryland Regional Medical Center. The AOJ faxed the facility the Veteran’s VA Form 21-4142a for the release of medical records. After review, the Board notes that the AOJ has not associated any records from this treatment facility with the claims file. In December 2019, the Veteran submitted a VA Form 4142a. Thereby, the Veteran authorized the release of records for Miner’s Hospital. On February 10, 2020, the AOJ notified the Veteran that his records were requested from Miners Hospital. On the same day, a Report of Contact was associated with the claims file. Therein, the AOJ relayed that it was unable to locate the contact information for Miners Hospital. The claims file contains no other document generated by the AOJ for its attempts to secure the Veteran’s treatment records. The Board notes that strict compliance with remand directives is not an absolute necessity; however, substantial compliance is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). Since any analysis for these service-connection claims require the available and obtainable evidence that pertains the Veteran’s claimed disabilities, the AOJ’s failure to explain in writing why further attempts to locate or obtain any treatment records from Miners Hospital would be futile renders the its actions non-compliant. On remand, the AOJ must attempt to secure any pertinent, outstanding records identified by the Veteran for the service-connection claims listed above. If the AOJ is unable to obtain the records, the AOJ should contact the Veteran and invite him to obtain and submit the records. Consequently, the matters are REMANDED to the agency of original jurisdiction (AOJ) for the following action: 1. Assist the Veteran by contacting the relevant authority with possession of records at Miners Hospital in Frostburg, Maryland. If the RO cannot locate such records, it must specifically document the attempts that were made to locate them, and explain in writing to the Veteran why further attempts to locate or obtain the records would be futile and invite him to obtain and submit the records. 2. With the Veteran’s assistance, the AOJ must determine if there are any more recent medical treatment records from either VA facilities or private treatment facilities and obtain them if available. 3. After any additional private and/or government treatment records are associated with the claims file, addendum examination reports should be obtained from the March 2020 VA examiner. After review of any additional treatment records, the VA examiner must address the following: (a.) Does the Veteran have any current immune system disorder? If so, please list such diagnosis or diagnoses associated with such disorder. (b.) Does the Veteran have any current gastrointestinal disorder(s) or residuals? If so, please list such diagnosis or diagnoses associated with such disorder. (c.) If the Veteran has an immune system disorder, is it as likely as not (i.e., probability of 50 percent or more) that the immune system disability had its onset during, or is otherwise related to service, to include as due to an in-service infection. (d.) If the Veteran has any gastrointestinal disorder(s), is it as likely as not (i.e., probability of 50 percent or more) that the gastrointestinal disability had its onset during, or is otherwise related to service, to include as due to an in-service infection. The examiner must specifically address the Veteran’s contention that he has experienced digestive troubles since service and was prescribed antibiotics for an infection in service. The examiner must comment on any credibility issues raised by the record from a medical perspective. 4. Following the above development, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of arthritis of the bilateral hips and right hip replacement. For any hip disability identified, the examiner must opine whether it is at least as likely as not (i.e. probability of 50 percent or greater): It was caused or aggravated beyond its natural progression by his claimed immune system disorder and/or steroid treatment. 5. The AOJ must ensure that the examination report requested above is in compliance with the directives of this remand. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures at once. 6. After completing the above development, the AOJ should review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 7. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the claims for service connection. If the benefits sought are not granted, the AOJ must then issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.