Citation Nr: 21005696 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 10-09 634 DATE: February 2, 2021 ORDER Service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) anxiety, depression, and alcohol dependence, is denied. Service connection for hearing loss is denied. Service connection for psoriasis with psoriatic arthritis is denied. REMANDED Service connection for hepatitis C (HCV). Service connection for a traumatic brain injury (TBI).   FINDINGS OF FACT 1. There is not credible evidence of a traumatic stressor during service and a current psychiatric disorder is not due to service. 2. The Veteran’s hearing loss is not due to service. 3. The Veteran’s psoriasis with psoriatic arthritis is not due to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder, to include PTSD, anxiety, depression, and alcohol dependence, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.301, 3.303, 3.304, 4.9. 2. The criteria for service connection for hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 3. The criteria for service connection for psoriasis with psoriatic arthritis have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1976 to July 1976 and Reserve service from July 1979 to July 1981. The case is on appeal from September 2005 and October 2006 rating decisions. The Veteran testified at a Board hearing in March 2017. In a September 2017 decision, the Board granted service connection for tinnitus, and denied service connection for a dental disorder and COPD. At that time, the Board remanded the claims remaining on appeal for further development and consideration. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 1. Service connection for a psychiatric disorder, to include PTSD, anxiety, depression, and alcohol dependence. Specific Legal Criteria Service connection for PTSD requires medical evidence diagnosing the condition in accordance with § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If a posttraumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a posttraumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran’s service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). Analysis The Veteran maintains that he has a current psychiatric condition arising from service. He claims that he experienced military sexual trauma (MST). The Veteran recalls several incidents. First, during boot camp he was made to stand on a table in front of everyone while the drill sergeant made sexual comments. After boot camp graduation while still 17, the Veteran and some fellow service members went off base and hired some prostitutes, which resulted in uncomfortable sexual situations. He reports having been close to his family before boot camp, but became more withdrawn and less receptive after service. Finally, the Veteran attended a rock concert, where he was slipped something causing memory loss and was forced to be in uncomfortable sexual situations again with prostitutes. He first started having nightmares during bootcamp. With regard to the Veteran’s claims for PTSD and alcohol dependence, a review of the record discloses diagnoses of an anxiety disorder and depression. Therefore, the Board considers this to be a broader single claim of service connection for a psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). VA medical records show the Veteran has been diagnosed with various psychiatric conditions, including adjustment disorder with depressed mood (March 2005); anxiety disorder not otherwise specified (NOS) (May 2008); and major depressive disorder (February 2016). A diagnosis of substance abuse, especially alcohol, is also shown. A diagnosis of PTSD is also shown. PTSD was first diagnosed in May 2006. Other VA medical records, such as in August 2007, August 2013, and most recently in July 2020, also notate a PTSD diagnosis. It is assumed that these diagnoses are supported by the applicable diagnostic criteria. Cohen v. Brown, 10 Vet. App. 128, 153 (1997). A VA examiner in January 2018 concluded that the Veteran did not meet the diagnostic criteria for PTSD. However, there is not a preponderance of the evidence against the other PTSD diagnoses of record. Hence, this diagnosis is established. The Veteran has also been diagnosed with a personality disorder. Service connection for personality disorders cannot be established as a matter of law. The VA examiner in January 2018 opined why the evidence indicated the preexistence of this condition and why it was not aggravated by service. Hence, there is no indication of a superimposed condition. 38 C.F.R. §§ 3.303(c), 4.9, 4.127; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). Notwithstanding the existence of these multiple psychiatric diagnoses, the alleged traumatic events during service are not shown by any independent evidence. Previously, the Board’s September 2017 remand found that it was necessary to obtain an opinion as to whether the Veteran’s reported behavioral changes indicated that an MST occurred. The VA examination was conducted upon remand in January 2018. That examiner did not answer this question, as directed in the Board’s September 2017 remand. However, the Board had directed the examiner to answer the question only if PTSD was diagnosed. As the examiner did not diagnosis PTSD, the examiner did not need to answer the conditional question regarding MST. Hence, the Board finds substantial compliance with the remand directives to this end. Otherwise, the Board finds that the Veteran’s own statements are not sufficiently reliable to establish the occurrence of any stressor event during service. The Veteran is simply shown to not be a reliable historian. In support of his claim, he testified at his Board hearing that he started having such PTSD symptoms as nightmares during service. Board Hr’g Tr. 7. Moreover, he testified that all of his symptoms occurred before a motorcycle accident in 2004. Board Hr’g Tr. 18-19. Yet, his VA medical records show widely disparate accounts of his history. Somewhat favorable, he has provided some statements during VA treatment relating his symptoms to service. For example, he stated during treatment in January 2007 that he felt he was negatively influenced at too young an age during service. During VA therapy in March 2008, he discussed a traumatic memory from basic training when he was forced to stand on a stool and talk to a lightbulb. In August 2013, he reported having more dreams and intrusive thoughts about his own serious accident a few years back, but he also brought up a couple of events from service that still bothered him. During VA treatment in July 2018, he stated his belief that he had PTSD related to his experiences during service. One week later, he reported experiencing MST in addition to the other traumatic events. By comparison, other VA and private (non-VA) medical records show differing accounts. For example, he underwent a private competency evaluation in July 2004, one month after the motorcycle accident. At that time, the Veteran affirmatively denied any psychiatric history apart from alcohol abuse. It was noted that his history was “somewhat sketchy” as he was “not forthcoming with details.” The Board finds his statement at that time to be especially probative because it was more proximate in time to the events in question and was made without the conflicting interest apparent in the context of his current claim. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness) He underwent a behavioral assessment at VA in March 2005 where he reported symptoms in the context of being divorced twice, the motorcycle accident, and losing his job. In a separate March 2005 report, he denied any prior sexual abuse. In a further evaluation in March 2005, the Veteran reported that the motorcycle accident had “diminished his world.” In January 2007, he reported depression for the past 15 to 16 years starting during his first marriage. (The Board observes that this would have been in approximately 1991, which was more than 10 years after separation from service in July 1981.) He felt the motorcycle accident had added to his depression. He reported again in February 2018 that he had issues with depression and PTSD from the motorcycle accident. Even more inconsistent, he reported during a comprehensive VA mental health evaluation in February 2016 that he first began having difficulties with depression and anger in elementary school. The provider detailed multiple potentially traumatic events in childhood as reported by the Veteran. The Veteran also stated his belief that the events of his service impacted how he related to people since then. He denied MST. In short, the Veteran’s account of his psychiatric history has been dramatically inconsistent across time and the context of the reporting. At times, he has endorsed supporting statements regard service. There are also instances where he has reported multiple stressors while leaving out any mention of the in-service stressors. At other times, he has affirmatively denied symptoms related to or since service. There are other indicia in the claims file indicating that he is not a reliable historian. By way of example, the July 2004 treatment records for the motorcycle accident show that he did not lose consciousness. He was treated at the hospital for bruises and scrapes across his body, plus a headache, and was released several days later. Yet, a VA behavioral assessment in May 2006 notes his report that he had been in a coma for 3 days after the motorcycle accident in July 2004. This is representative of other instances of exaggeration or misrepresentations. Also representative of these inconsistencies, he reported during VA treatment in January 2007 and March 2007 that he was let go from a job with his state’s correctional department after being accused of being in a fight. In comparison, he reported during treatment n March 2005 and at his March 2017 Board hearing that he was fired from this job after being suspected of being part of an “outlaw biker gang.” Board Hr’g Tr. 15. Finally, the medical records also include multiple instances of direct attempts at untruthfulness for purposes of secondary gain. Most notably, during VA treatment in June 2020, he underwent two urine drug screens one week apart. Both were positive for amphetamines. The Veteran initially attempted to explain the positive results by stating that he had used over-the-counter cold medications. When he was confronted with the fact that the excessively high levels ruled out the ingestion of cold medications, the Veteran then stated that “maybe” someone had given him an Adderall instead of an aspirin which made him feel “weird” afterward. Similarly, one year prior, in March 2019, the Veteran had presented for a urine drug screening with a sample of urine wrapped in a plastic bag, which the Veteran stated had been on his desk at work all night. Moreover, with further regard to his past history of substance use, he reported in a July 2005 HCV questionnaire that he had a history of intranasal cocaine use. He reported during VA treatment in March 2005 that he had used cocaine/marijuana and methamphetamine in the 1970s, but had not used drugs since. He gave a similar history March 2007, when he reported his last use of marijuana 20 years prior. Consistent with these statements, during a behavioral assessment at VA in March 2005, it was noted that this last polysubstance abuse had been in 1989. Yet, in May 2006, he stated that he smoked marijuana, 1 to 2 joints per day, with his last use one week prior. (The Board observes that this would have been during the period of non-use he reported in March 2007.) During treatment in April 2005, he omitted his prior use of cocaine where specifically asked. Overall, the Veteran’s statements with specific regard to his psychiatric symptoms and more generally in other contexts show that he is simply not a credible historian. This evidence impeaches his credibility to such an extent that his current statements, including those regarding his in-service stressors and those indicating symptoms since service, cannot be considered sufficiently probative to establish the stressor events or the fact of ongoing symptoms since service. It is true that a PTSD stressor based on a personal assault need not be documented in the file to establish the occurrence of the event. The Board is also mindful of his representative’s assertion that the Veteran did not feel comfortable discussing his MST until recently. See April 2017 brief. However, there must be other evidence in the file to support the occurrence of the MST events. See 38 C.F.R. § 3.304(f)(5). This is especially important considering the facts impeaching the Veteran’s credibility. The Veteran’s service records do not provide any such objective indicia. It is true that he requested an early discharge. However, he stated in a June 2006 PTSD stressor statement that this was because he had entered service with a promise to go to a certain school, which promise was not kept. His service records support this reason. There is no indication that his early separation might have been a pretext to remove himself from the traumatic duty assignment. He reenlisted in the same branch of service approximately 3 years later. It appears reasonable to assume that he would not have wanted to rejoin the same service branch if his initial period of service had been as traumatic as described. Hence, his reenlistment further indicates that he did not consider his initial period of service to have been traumatic. Hence, a stressor event during service is not established. Even if the claimed stressor events during service did occur, the evidence is against a nexus to those events. At VA in May 2006, he was diagnosed with PTSD from the motorcycle accident injuries. In connection with his current claim, he underwent a comprehensive VA examination in January 2018. The examiner concluded that the Veteran did not meet the diagnostic criteria for PTSD, but that his major depressive disorder was less likely than not related to service. The examiner gave an extensive rationale. For sake of brevity, the Board will summarize the examiner’s rationale as being that the Veteran’s symptoms arose with the 2004 motorcycle accident. He had interpersonal difficulties, affective instability, and rejection sensitivity beginning in early adolescence and continuing through adulthood with excessive alcohol use that has likely been an attempt to deal with the distress of his social isolation, anxiety and dysphoric feelings that are a part of his personality disorder. Otherwise, the VA examiner found insufficient supporting documentation to link the Veteran’s psychiatric condition with service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To this end, the VA examiner relied on an absence of documented evidence. As there is no objective supporting evidence and the Board has found the Veteran’s own account not credible, this VA examiner’s rationale does not impermissibly rely on an absence of evidence as negative absence. See, e.g., Miller v. Wilkie, 32 Vet. App. 249, 258 (2020); McKinney v. McDonald, 28 Vet. App. 15, 30 (2016). The Veteran testified at his Board hearing that two VA providers had linked his condition to service. Board Hr’g Tr. 34. As indicated, he is not considered a reliable historian. Moreover, these opinions are not documented in his VA medical records. Thus, even assuming the Veteran is accurately and comprehensively conveying these opinions, the Board is unable to assess the evidentiary value of such medical opinions. More specifically, the Board cannot determine the factual premise or the reasoning underpinning such favorable medical opinions. Therefore, these opinions have little probative value when compared with the VA examiner’s opinion. See Nieves-Rodriguez, 22 Vet. App. at 304. Collectively, this evidence makes it less likely than not that a current psychiatric diagnosis is related to service. The Veteran is diagnosed with substance use, including alcohol dependence. Service connection for such conditions is available only as secondary to another disorder. 38C.F.R. §3.301(a). In this case, the Veteran specifically claims that the disorder is secondary to his PTSD. As service connection for the primary condition is being denied, service connection for the secondary condition must also be denied as a matter of law. In sum, the preponderance of the evidence is against the claim; thus, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for a psychiatric disorder is not warranted. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d).   2. Service connection for hearing loss. Specific Legal Criteria For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Analysis The Veteran maintains that he has hearing loss related to noise exposure during service. At his Board hearing, he testified to noise from being the loader on a gun turret without hearing protection. Board Hr’g Tr. 19. He also described incidents where he was exposed to half-track amphibious vehicle noise and engine room noise. Board Hr’g Tr. 19-20. He testified that he first noticed a hearing impairment during service. Board Hr’g Tr. 22. In the instant case, the Veteran has a current disability. His hearing acuity at an October 2019 VA examination was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 60 65 75 75 LEFT 40 50 55 65 70 Speech recognition scores were 64 percent right ear and 64 percent left ear. Because auditory thresholds at this examination were 40 decibels or greater in any of the frequencies, a hearing loss for VA purposes is established. See 38 C.F.R. § 3.385. The Veteran’s DD 214 shows that his primary specialty during his initial period of service was BM-9720, which is consistent with boatswains mate. This rating is associated with a high probability of hazardous noise exposure. Hence, for purposes of this decision, the Board finds sufficient evidence of such noise exposure during service. The remaining question is whether the Veteran’s current hearing loss is due to that noise exposure. The Veteran testified at his Board hearing that his hearing doctors (presumably his audiologists) said his hearing aids were service-connected. Board Hr’g Tr. 34. As indicated, he is not considered a reliable historian. Moreover, these medical opinions are not documented in his VA medical records. Thus, even assuming the Veteran is accurately and comprehensively conveying these opinions, the Board is unable to assess the evidentiary value of such a medical opinion. More specifically, the Board cannot determine the factual premise or the reasoning underpinning such favorable medical opinions. Therefore, these opinions have little probative value. See Nieves-Rodriguez, 22 Vet. App. at 304. A VA examiner in October 2019 opined that it is less likely than not the Veteran’s hearing loss is due to in-service noise exposure. The examiner found that the Veteran had served for 6 months on active duty and his specialty was Boatswains Mate, which was considered a high probability for hazardous noise exposure. The examiner noted that the Veteran had an entrance audiogram in January 1976 which revealed hearing within normal limits from 500-4000 Hz. The examiner found no evidence of a separation audiogram, and service treatment records were silent for hearing loss. The examiner found no evidence the Veteran developed hearing loss within a year of service. The examiner concluded that the claim is “not strong due to the relatively short time span of active duty.” The examiner explained, although there is a well-established relationship between noise exposure and hearing loss, hearing loss is not conceded on noise alone, as there must be a nexus of auditory damage to relate the current hearing loss to in-service noise exposure and not another etiology. The examiner found the evidence to be against a nexus in this case The Board finds this VA examiner’s opinion probative. The examiner did not account for the Veteran’s second period of service. However, the examiner conceded noise exposure, and there is no indication of material noise exposure during his later period of Reserve service. Likewise, the examiner did not account for the Veteran’s own testimony indicating that he first noticed a hearing impairment during his service. However, the Veteran is not a credible historian. Hence, his own testimony indicating symptoms first arising during service is not probative absent some corroborating evidence which is absent. Thus, overall, this VA examiner’s opinion is the most probative evidence of record on the nexus question. In sum, the preponderance of the evidence is against the claim; thus, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for hearing loss is not warranted. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). 3. Service connection for psoriasis with psoriatic arthritis. The Veteran maintains that he first had symptoms of psoriasis proximate in time to service. He testified that he first started seeing the psoriasis in 1978, when his elbows were getting scaly all the time. Board Hr’g Tr. 31. He explained that he was out of service by then, but was in the Reserve. Board Hr’g Tr. 32. There is no dispute here that the Veteran is diagnosed with psoriatic arthritis and psoriasis. This diagnosis was first suspected in October 1995, was confirmed in December 1999, and has been continuously treated up to the present. The Veteran was not treated for any skin condition during active duty service, nor does he contend such. He testified that the symptoms he believed to be psoriasis first appeared in 1978. As this was greater than one year after his service separation in July 1976, service connection on a presumptive basis for arthritis is not available. See 38 C.F.R. §§ 3.307, 3.309(a). Moreover, there is no credible indication that it preexisted and was aggravated during his second period of Reserve service from July 1979 to July 1981. A May 1979 Reserve enlistment examination was negative for the condition. The Veteran’s noncredible testimony is not sufficient to establish preexisting. Moreover, he has not indicated any material worsening during the time period covering his Reserve service. Hence, service connection on this basis cannot be established. See 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Smith v. Shinseki, 24 Vet. App. 40, 46 (2010). Moreover, absent such an indication, no further development is needed in this regard. A VA examiner in February 2018 opined that this condition developed after the Veteran’s time in service and thus had no relation to an in-service injury, event or illness. The examiner observed that there was no evidence with regard to psoriatic arthritis while the Veteran was in service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. Overall, this evidence makes it more likely than not that the Veteran’s current condition is unrelated to service. As an alternative theory of entitlement, the Veteran further testified that he may have psoriasis due to Agent Orange exposure during service. The Board’s prior remand found that the Veteran was not exposed to Agent Orange or other tactical herbicide during service. The Board explained that psoriasis is not listed as a disease presumptively caused by Agent Orange. 38 C.F.R. § 3.309(e). Further, the Veteran did not serve during the Vietnam War, nor did he serve in the Republic of Vietnam or other area where one is presumed to have been exposed to Agent Orange. The Joint Services Records Research Center (JSRRC) also found no evidence that the ship on which the Veteran was station stored, tested, or transported tactical herbicides, such as Agent Orange. Since the Board’s remand, there has been no further evidence received on this question. Hence, there is no reason to revisit the Board’s prior finding that the Veteran was not exposed to Agent Orange during service. As such, service connection on a presumptive basis for Agent Orange exposure is not available. See 38 C.F.R. §§ 3.307, 3.309. In sum, the preponderance of the evidence is against the claim; thus, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for psoriasis with psoriatic arthritis is not warranted. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND 1. Service connection for HCV. The Board previously remanded the claim to obtain an adequate opinion addressing whether the Veteran may have HCV due to service. Upon remand, a VA examination was conducted in February 2018. With regard to HCV, the VA examiner’s ultimate opinion was that “I cannot say with greater than 50% probability that his hepatitis C is directly due to reuse of needles during inoculation while he was in service.” The Board observes that the VA examiner’s opinion is phrased in a way giving the appearance that the examiner shifted the burden of proving the claim onto the Veteran with a higher degree of probability than is needed. That is, the Veteran is not required to show to a degree of greater than 50 percent probability that his HCV is due to reuse of needles. The examiner only needed to determine if it was at least equally likely (at least 50-50 percent probability) that reuse of needles could have caused his HCV. It is not clear if this was a misunderstanding or simply a typographical error on the examiner’s part. However, as this is fundamental and goes to the ultimate burden of proof, the Board finds that remand is needed for clarification. To this end, as observed herein above, the Veteran is not considered reliable historian. While it is not in material dispute at this point that he was likely inoculated with an airgun jet injector, the Veteran has inconsistently reported other potential HCV risk factors. For example, in a July 2005 VA HCV questionnaire, he reported intranasal cocaine. On other occasions, such as a March 2007 VA Hepatology consultation for HCV, he did not report past cocaine use where asked. Relatedly, he reported on his HCV questionnaire that he did not have a past history of high-risk sexual activity. Yet, in connection with his PTSD claim, he has repeatedly reported having sexual relations during service with prostitutes. See e.g., March Board Hr’g Tr. 14; January 2018 VA examination. Finally, on his July 2005 HCV questionnaire, he marked that he was not exposed to his knowledge as a healthcare worker to any contaminated blood or fluids. By comparison, he testified at the Board hearing that when caring for people who were bleeding, he always used gloves. Board Hr’g Tr. 34. These inconsistencies bear on whether he may have risk factors other than airgun jet inoculations. Upon remand, the VA examiner must consider these factors in determining if the inoculations are as likely as any other potential risk factor to have caused his HCV. 2. Service connection for a TBI. As with the HCV claim, the Board previously remanded the TBI claim to obtain an adequate opinion addressing whether the Veteran may have a TBI due to service. Upon remand, a VA examination was conducted in February 2018. The same VA examiner, with regard to TBI, the examiner opined that “I cannot say with greater than 50% probability that his traumatic brain injury is directly due to being struck during a boxing match during his time in service.” Again, this VA examiner’s opinion appears to place the burden of proof at a higher level than is necessary to grant the claim. As such, a new opinion is warranted. It is also important to point out here that the Veteran is again seen to be an inconsistent and unreliable historian. Essentially at this point, the material question is whether an in-service head injury caused or contributed in any way to a TBI condition. This question is critical because the Veteran has identified numerous other head injuries outside of service. Overall, the Veteran has reported head trauma due to (1) hitting his head every morning while sleeping on the top bunk located under a pipe during Navy service; and (2) being knocked out in service during a boxing match; (3) at age 6 requiring 13 stiches; (4) from a fistfight during which he was hit with a roll of quarters on the right check; (5) as a result of a motorcycle accident where he was thrown over the handle bars into the woods; (6) (possibly a second) motorcycle accident which resulted in the Veteran being in a coma for three to five days; and (7) getting kicked by a horse. The Veteran has been inconsistent in attributing his symptoms, primarily headaches and memory loss, to service. For example, VA medical records, such as in March 2005, diagnosed a cognitive disorder due to the 2004 motorcycle accident. Later in March 2005, the Veteran stated he had poor short-term memory problems since his motorcycle accident with head injury. During an April 2005 VA Neuropsychiatric evaluation, he reported the multiple other head injuries, but not a service-related head injury. In January 2007, he described only the motorcycle accident. A September 2007 VA electromyogram (EMG) test states he suffered a TBI at the time of the motorcycle accident. Then, during an October 2009 VA Hematology consultation, it was noted that the Veteran had memory loss after head traumas involving the motorcycle accident, a fall with head injury, and was hit in the right orbit area during an assault. A February 2016 VA Gastroenterology consultation notes a “soliloquy” from the Veteran indicating memory problems attributed to the motorcycle accident. At a January 2016 VA Optometry appointment, the Veteran reported the motorcycle accident and getting kicked in the eye by a horse. In February 2016, he reported falling and “split[ting] his head open in first grade.” His primary care provider noted in April 2016 that the Veteran had been discovered to have a stroke; the Veteran was at a loss to account for the stroke except to note his 2004 motorcycle accident where he sustained a head injury. At a February 2018 VA examination, the Veteran reported the 2004 motorcycle accident, but also stated that in the 1970s he had several incidents where he was struck in the head, including boxing as well as when he hit a steam pipe while working on a ship on active duty. Most recently, at an August 2018 VA Speech consultation, the Veteran reported a history of multiple head injuries, with the most significant injury occurring during a motorcycle accident in 2004. Even the Veteran’s attorney representative contentions have been inconsistent. For example, in a June 2014 VA Form 9, the attorney wrote that the TBI is the “result of [a] motorcycle accident related to [PTSD].” In an April 2017 brief, the same representative averred that the Veteran had TBI symptoms first arising from the events of service and not the motorcycle accident in 2004. Overall, this evidence demonstrates a wide and varying account of multiple different head injuries and symptoms associated with those various head injuries. Of further note, an evaluation conducted by the Social Security Administration (SSA) in June 2007 indicated that the Veteran did not suffer any brain damage in connection with the 2004 accident. This is a potentially favorable finding. In short, the Board finds that the February 2018 VA examiner’s opinion is inadequate as it placed a greater burden of proof on the Veteran’s claim. A new VA opinion is warranted to this end. The examiner’s mistake does not diminish the inconsistency in the Veteran’s report of his head injuries and the onset of his claimed TBI symptoms, which must be taken into consideration upon remand. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician regarding the Veteran’s hepatitis C. An in-person examination of the Veteran should be arranged if determined necessary by the appointed examiner. The examiner is asked to consider whether the Veteran’s hepatitis C diagnosis is at least as likely as not related to an in-service injury, event, or disease, especially airgun jet inoculations. To the extent necessary, the examiner is asked to consider the multiple other potential risk factors, including the inconsistencies in his reporting of those risk factors (as described in greater detail herein above). In doing so, the examiner should address whether the in-service inoculations are as equally likely as any other potential risk factors to have caused his hepatitis C. 2. Obtain an opinion from an appropriate clinician regarding the Veteran’s TBI. The opinion should be given by one of the four designated specialists (physiatrist, psychiatrist, neurologist, or neurosurgeon) for TBI claims. An in-person examination of the Veteran should be arranged if determined necessary by the appointed examiner. The examiner is asked to address the following: (a.) Did a TBI condition preexist the Veteran’s active service? The examiner should consider the Veteran’s statements indicating head injuries as a child. (b.) If preexisting his service, did the condition worsen (i.e., increase in severity) during service? If yes, was that worsening due to the natural progress of the disease? How certain are you in your answers to questions (a) and (b)? Would any provider with the same information reasonably be able to reach a different conclusion? (c.) If you determined in questions (a) and (b) that a TBI condition preexisted service, is it at least as likely as not (i.e., at least equally probable) that the current diagnosis represents the present manifestation of that same condition? (d.) If not preexisting service, is it at least as likely as not (i.e., at least equally probable) that any current diagnosis had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, such as hitting his head on a pipe or being in a boxing match? RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bosely, 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.