Citation Nr: 21006666 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 14-10 672 DATE: February 4, 2021 REMAND Entitlement to service connection for a left ankle condition, to include as secondary to the service-connected right ankle condition, is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Navy from March 1980 to February 1984. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). In March 2015, the Veteran provided testimony before a Veterans Law Judge. A copy of the transcript is associated with the claims file. This matter was previously remanded by the Board for further development in November 2015 and April 2020. In November 2015, the Board reopened the previously denied claim for entitlement to service connection for a left ankle condition. The Board notes that in October 2019 and February 2020 correspondences, the Veteran was notified that the Veterans Law Judge (VLJ) who presided over his March 2015 hearing no longer worked at the Board and the Veteran was given the option for another hearing before another VLJ. 38 C.F.R. § 19.3(b). The Veteran did not respond to either correspondences. As such, the Board will proceed to render a decision based on the evidence of record. The Board also notes the Veteran contends that he sought treatment at the Brick Out-Patient Clinic, but that the RO failed to obtain and review those records. See February 2020 Appellate Brief. However, treatment records from the Brick, New Jersey CBOC are associated with the claims file. See January 2019 CAPRI. Entitlement to service connection for a left ankle condition, to include as secondary to the service-connected right ankle condition, is remanded. With regard to the claim for service connection for left ankle disability, the Board finds that the opinions obtained by the RO, to include on the last remand are inadequate, and remand is required to obtain additional opinion for the VA to fulfill the duty to assist the Veteran. The Veteran contends that his left ankle condition is related to service. Specifically, on numerous lay statements, to include while presenting testimony during his hearing before a Veteran’s Law Judge, the Veteran noted that he started experiencing pain in his left ankle after his fall/accident during his active service; the same accident in which his right ankle disability is service-connected for. To this end, the Board also noted that VA examinations and opinions already acquired by the VA has all confirmed that the Veteran’s left ankle disability is of the type not caused by ‘wear and tear,’ but rather traumatic injury. As such, the Board finds that while there is no actual medical or treatment record of a complaint or treatment for a left ankle injury during and after his fall during service, the evidence is adequate to trigger the VA’s duty to acquire an examination that speak to the nature and etiology of his claimed left ankle disability as it relates to his active service. The Board additionally notes that the VA’s statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). As the VA has already provided a VA examination and opinion regarding secondary etiology to the right ankle, such opinions are rendered inadequate/incomplete as they do not address any theories of direct service connection. Consequently, remand is required to acquire an addendum opinion. The matters are REMANDED for the following action: 1. Obtain the Veteran’s updated VA treatment records. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s left ankle disability is at least as likely as not (50 percent or greater) arose during his active service, or was caused by any aspect of his active service, to include the fall that injured his right ankle, which is currently service-connected. The examiner must explicitly address lay contentions by the Veteran, to especially include his hearing testimony, where he asserts that pain in his left ankle began during his active service after his accident/fall. The electronic claims file must be made available to, and be reviewed by, the examiner. The examiner must note such review in the examination report. An in-person examination is not necessary unless the examiner determines otherwise. The examiner must provide a complete explanation for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Asfaw, 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.