Citation Nr: 21010670 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 03-16 549 DATE: February 25, 2021 REMANDED Service connection for residuals of a gunshot wound to the left arm with radial nerve paralysis is remanded. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. Service connection for residuals of rheumatic fever is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1970 to June 1973 in the U.S. Army with additional service in the Louisiana Army National Guard and California Air National Guard. This matter comes before the Board of Veterans’ Appeals (Board) from April 2002 and June 2005 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In March 2011, the Veteran testified before a Veterans Law Judge (VLJ) who is no longer employed by the Board. A transcript of the hearing is of record. In December 2020, the Veteran declined another Board hearing. This case was most recently before the Board in July 2015, at which time the issues on appeal were remanded for further development. Although further delay is regrettable, for the reasons below, the Board finds that there has not been substantial compliance with the prior remand directives. Therefore, another remand is required. See Stegall v. West, 11 Vet. App. 268 (1998). Residuals of Gunshot Wound The July 2015 Board remand instructed the RO to contact the Louisiana Army National Guard and the California Air National Guard and request any available personnel records for the Veteran showing his periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) and to make a formal finding if the records were determined to be unavailable. The record shows that the RO requested records from the Adjutant General of California and Louisiana in March 2016. Thereafter, the Department of the Army Headquarters, California Army National Guard responded and stated that no records were found. The response indicated that the Veteran served in the California Army National Guard, however other military personnel records show that he served in the Air National Guard of California and as a Reserve of the Air Force. Accordingly, the Board finds that remand is warranted to conduct another search for the Veteran’s records pertaining to his military service. Additionally, in an August 2016 Notification Letter, the RO informed the Veteran that the Adjutant General of Louisiana was contacted in March 2016, however they responded stating “no records found.” The Board notes, however, that the negative response from the Adjutant General of Louisiana is not documented in the claims file. Accordingly, these records should also be requested on remand. The Board also notes that while the Veteran was informed that the requested records were unavailable, a formal finding was not made as to the unavailability. Accordingly, a formal finding should be made on remand if the requested records are unavailable. Acquired Psychiatric Disorder The Veteran was afforded a VA examination an opinion in April 2016 and an addendum opinion was obtained in August 2017. The Board finds that the April 2016 and August 2017 opinions are inadequate for adjudication purposes. Notably, the rationales stated that the Veteran does not have a diagnosis of PTSD. However, the Veteran’s medical records contain multiple psychiatric diagnoses, including PTSD, anxiety, depression, bipolar disorder, and schizoaffective disorder. Moreover, the examiners did not provide an opinion as to whether the Veteran’s psychiatric diagnoses other than PTSD or schizoaffective disorder are related to service or address whether the Veteran’s psychiatric disability is related to his in-service personal assault. Accordingly, an addendum opinion is needed. The Veteran also contends that he has anxiety and depression secondary to his service-connected tinnitus. See August 2017 Correspondence. Accordingly, an opinion addressing secondary service-connection should be obtained on remand. Residuals of Rheumatic Fever In July 2017, a VA examiner opined that the Veteran’s claimed disability was less likely than not incurred in or caused by service because the Veteran does not have evidence of rheumatic heart disease and not all rheumatic fever leads to rheumatic heart disease. The Board finds that the opinion is inadequate for adjudication purposes because the physician did not opine as to whether the Veteran’s heart disability is otherwise related to service. Accordingly, an addendum opinion is needed. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete service personnel and service treatment records pertaining to his service in the California Air National Guard and Louisiana Army National Guard. Verify all active duty for training and inactive duty training dates for service in the California Air National Guard and Louisiana Army National Guard. If necessary, a request should be made to the Defense Finance and Accounting Service (DFAS). Document all requests for information as well as all responses in the claims file. If unsuccessful, a Formal Finding of Unavailability should be prepared and associated with the claims file, and the Veteran notified. 2. Obtain an addendum opinion from an appropriate physician to determine the etiology of all documented psychiatric disorders. Following complete review of the evidence of record, the physician should address the following: (a.) Identify all psychiatric disorders diagnosed in the record, to include PTSD, anxiety, depression, bipolar disorder, and schizoaffective disorder. (b.) For each diagnosis, the physician should opine as to whether it is at least as likely as not (50 percent probability or higher) that the psychiatric disorder had its onset during active duty service or is otherwise etiologically related to any in-service injury, event, or disease, to include in-service personal assault. (c.) If the physician determines that the Veteran’s psychiatric disability is related to the 1969 motor vehicle accident, the physician should opine as to whether it is at least as likely as not that the Veteran’s psychiatric disability was aggravated by any in-service injury, event, or disease, to include in-service personal assault. (d.) The physician should also opine as to whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s psychiatric disorder was (1) caused or (2) aggravated by the Veteran’s service-connected tinnitus. The physician should consider the Veteran’s lay statements and his claimed stressors. A complete rationale should be provided for all opinions offered. 3. Obtain an addendum opinion from an appropriate physician to determine the nature and etiology of the Veteran’s claimed residuals of rheumatic fever, to include a heart disability. The claims file should be made available to the physician and review should be noted. If an examination is deemed necessary by the physician, then one should be scheduled. The physician should opine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s heart disability and/or any residuals of rheumatic fever had its onset during active service or is otherwise related to any in-service injury, event, or disease. The physician should consider the Veteran’s in-service cardiology treatment and treatment for pharyngitis and myalgia. Additionally, the physician should consider the Veteran’s claimed symptoms, including arthritis in the joints, rashes, heart disease, chronic colds, sinusitis, pressure and pain in the chest, cramps, and muscle spasms. See July 2001 Statement in Support of Claim. A complete rationale must be provided for all opinions offered. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Kernen, 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.