Citation Nr: 21006221 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 15-30 054 DATE: February 3, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, schizophrenia, and psychosis is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for a left ankle condition is remanded. Entitlement to service connection for bruxism is remanded. Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for left foot bunion is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from May 2006 to July 2011. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. This case was previously before the Board in August 2018, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, schizophrenia, and psychosis is remanded. 2. Entitlement to service connection for migraine headaches is remanded. 3. Entitlement to service connection for a left ankle condition is remanded. 4. Entitlement to service connection for bruxism is remanded. 5. Entitlement to service connection for bilateral pes planus is remanded. 6. Entitlement to service connection for left foot bunion is remanded. In August 2018 the Board remanded this claim so that the Veteran could be scheduled for VA examinations. In May 2019 it was noted the Veteran did not report for his scheduled VA examinations. The United States Court of Appeals for Veterans Claims (Court) has held that the burden is upon VA to demonstrate that notice was sent to the claimant’s last address of record and that the claimant lacked adequate reason or good cause for failing to report for a scheduled examination. Hyson v. Brown, 5 Vet. App. 262, 265 (1993); see also Connolly v. Derwinski, 1 Vet. App. 566 (1991). Notification for VA purposes is a written notice sent to the claimant’s latest address of record. See 38 C.F.R. § 3.1(q) (2019). In this case, VA treatment records in April 2019 indicate the Veteran presented for assistance with rent payments. The Veteran and a VA social worker contacted the Veteran’s landlord to determine if the landlord was willing to work out a plan with the Veteran. The landlord did not indicate that he was willing to work with the Veteran. A few days later the Veteran reported that he was planning to sleep in his car or go to a shelter. In May 2019 it was noted that he had been staying in a homeless shelter. In February 2020 it was noted he was staying in a hotel. In August 2020 it was noted that the Veteran had moved back and forth a number of times. The Board finds that a remand is required in this case to afford the Veteran an opportunity to attend VA examinations, as the record suggests that the notice of examination scheduling may not have been mailed to the Veteran’s current address. The Board notes that December 2020 VA treatment records suggest the Veteran may obtain employment as a long haul truck driver. VA treatment records also indicate the Veteran has had multiple inpatient psychiatric admissions. As such, VA examinations should be scheduled well in advance so the Veteran will be able to attend the examinations. The Veteran is hereby advised that the examinations in question are being scheduled to assist VA in properly adjudicating his claim, and that his failure to report for an examination may result in an evidentiarily limited adjudication of his claim. The Court has indicated that “[t]he duty to assist is not always a one-way street.” Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). If a veteran desires help with his claim, he must cooperate with VA’s efforts to assist him, to include reporting for scheduled examinations. Id. The matters are REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. Verify the Veteran's correct contact information, particularly his mailing address, by telephone if necessary, and indicate the correct address in the electronic claims file. Enlist the assistance of the Veteran's representative if necessary. 3. Contact the Veteran and request that he identify any pertinent private treatment records not already identified and obtained and, with the appropriate authorization, attempt to obtain those records and associate them with the claims file. 4. Schedule the Veteran for a VA examination by a VA or VA-contracted psychiatrist or psychologist to determine the nature and etiology of the Veteran’s acquired psychiatric disorder(s), to include PTSD, depression, psychosis, and schizophrenia. The electronic claims file must be reviewed by the examiner. After reviewing the claims file and examining the Veteran, the examiner should answer the following question: Is it at least as likely as not (probability of fifty percent or greater) that the Veteran’s acquired psychiatric disorder is related to his active duty service, or is otherwise related to any in-service disease, event, or injury? In forming the opinion regarding service connection, the examiner is requested to distinguish between substance abuse that is due to the Veteran’s own willful misconduct from that which is, or may be due to, the Veteran’s diagnosed psychiatric disorder(s). Also, the examiner is asked to consider any possible relationship or effects of those disorders with the Veteran’s claim for service connection of migraine headaches. 5. Schedule the Veteran for the appropriate VA examinations to determine the nature and etiology of the Veteran’s left ankle, bruxism, and migraine headache disabilities. The electronic claims file, to include the Veteran’s service treatment records, lay statements and testimony, and treatment records, should be reviewed by the examiner. After reviewing the claims file and examining the Veteran, the examiner(s) should opine to the following: Is it at least as likely as not (probability of fifty percent or greater) that the Veteran’s left ankle, bruxism and/or migraine headache disabilities are related to his active duty service, or are otherwise related to any in-service disease, event, or injury? The examiner for the migraine headaches disability is asked to consider the possible relationship and effects from the Veteran’s mental health disorders as noted above. 6. Schedule the Veteran for the appropriate VA examinations to determine the nature and etiology of the Veteran’s bilateral pes planus and left bunion disabilities. The electronic claims file, to include the Veteran’s service treatment records, lay statements and testimony, and treatment records, should be reviewed by the examiner. After reviewing the claims file and examining the Veteran, the examiner(s) should opine to the following: (a.) Does the evidence of record clearly and unmistakably (i.e., it is undebatable) show that the Veteran had bilateral pes planus and/or a left foot bunion that existed prior to his entry onto active duty? (b.) If the answer is yes, does the evidence of record clearly and unmistakably show that the preexisting bilateral pes planus and/or a left foot bunion was not aggravated by service or that any increase in disability was due to the natural progression of the disease? Please identify any such evidence with specificity. (c.) If the answer to either (a) or (b) is no, is it at least as likely as not that the Veteran’s bilateral pes planus and/or a left foot bunion had its onset in service? A detailed rationale supporting the examiner’s opinion should be provided. In forming the opinion, the examiner must consider all lay statements of record. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required or the examiner does not have the needed knowledge or training). Jones v Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. 7. If the Veteran does not attend any of his scheduled VA examinations the AOJ should associate with the record the Veteran’s notification of scheduled VA examination(s), including the address to which the notification(s) was sent. 8. Thereafter, readjudicate the issues on appeal as noted above. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period to respond. Roya Bahrami Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Smith, 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.