Citation Nr: 21010555 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 17-51 044 DATE: February 25, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) as due to military sexual trauma (MST) is granted. REMANDED Entitlement to service connection for a back disability, including as secondary to PTSD, is remanded. Entitlement to service connection for glaucoma, including as secondary to medication for PTSD, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The probative, competent evidence demonstrates that the Veteran’s PTSD is related to an in-service personal assault. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD due to MST have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1984 to September 1998. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing with the undersigned in August 2020. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and an in-service stressor. 38 C.F.R. § 3.304(f). In addition, there are special evidentiary procedures for PTSD claims based on personal assault. Patton v. West, 12 Vet. App. 272, 278 (1999). The Veteran claims that he was sexually assaulted by a superior officer while in service, but he did not report the assault. With respect to in-service stressor, the Veteran has consistently and credibly asserted that he was sexually assaulted by another service member while in service. The Board notes that there has been a formal finding that the Veteran’s service treatment records are unavailable. The Veteran’s records in evidence do reflect that a fellow servicemember who knew the Veteran prior to service and during service reported that the Veteran’s behavior began to change during service, including the Veteran becoming isolative and his attitude changing. The Veteran underwent a VA examination in March 2015 where he was diagnosed with PTSD due to MST. The examiner opined that while the Veteran has been diagnosed with PTSD due to a MST, and while he met criteria for such a diagnosis on the date of the examination and the examiner found him credible, the examiner was unable to find any documentation within his records that supported the occurrence of a trauma or any marker. The Veteran has been diagnosed with PTSD due to MST and has consistently asserted an MST occurred. This assertion is supported by the buddy statement attesting to changes in behavior during service as well as the VA examiner and the undersigned finding the Veteran credible. Therefore, resolving the benefit of the doubt in favor of the Veteran, the Board finds the probative, competent evidence demonstrates that the Veteran’s PTSD is related to service. As such, service connection for PTSD is warranted. REASONS FOR REMAND 1. Service connection for a back disability. The Veteran contends that his back condition has been exacerbated by his PTSD. The Board notes that the Veteran was involved in a motor vehicle accident in February 2010, which occurred after service. In January 2015, the Veteran submitted a private examination that stated that the Veteran’s chronic PTSD exacerbates his back pain. The Veteran has not undergone a VA examination to determine if his PTSD caused or aggravated a back disability, so remand is necessary to obtain such an examination. 2. Service connection for glaucoma. The Veteran contends that the medication from his PTSD has caused or aggravated his glaucoma. The Veteran has not undergone a VA examination to determine if the medication for his PTSD caused or aggravated his glaucoma. Such should be undertaken on remand. 3. TDIU. In light of the grant of service-connected for PTSD, as well as the remand of the intertwined service connection claims, the TDIU claim must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Castellano v. Shinseki, 25 Vet. App. 146, 161 (2011). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current disability of the back was (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected PTSD, to include as a result of physically tightening up due to stress and anxiety. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that current glaucoma was (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected PTSD, to include as a result of stress or because of medication taken for PTSD. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Hofmeister, Attorney Advisor 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.