Citation Nr: 21011199 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 15-08 665 DATE: March 1, 2021 REMANDED Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1974 to March 1982. This matter was previously remanded twice by the Board of Veterans’ Appeals (Board). In June 2018, the Board remanded to obtain a nexus opinion. In August 2019, the Board remanded to obtain an addendum opinion. Entitlement to service connection for residuals of a head injury, to include TBI residuals is remanded. The Board regrets any further delay in this matter, but finds additional development is needed before the Board can render a decision in this matter. The Veteran seeks service connection for residuals of a traumatic brain injury (TBI) that he contends are the result of a motor vehicle accident that occurred during his active service. More specifically, the Veteran contends that during this motor vehicle accident, he hit his head on the windshield and sustained multiple lacerations and contusions in the forehead. He states he also lost consciousness after the accident. While there is clear documentation in the claims file that the motor vehicle accident occurred during service, what is not clear from the evidence is whether the Veteran has any residuals from the claimed head injury he sustained during this accident. In other words, at issue is whether the Veteran has residuals of a TBI and whether any such residuals are due to the motor vehicle accident in service. As noted above, in June 2018, the Board remanded to obtain a nexus opinion. A VA examination was conducted in April 2019, and the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury/event. As rationale, the examiner stated the Veteran was involved in a motor vehicular accident but there was no available ER records of the motor vehicle accident and no documentation in the service treatment records for alteration or loss of consciousness. In August 2019, the Board found the April 2019 VA examiner’s opinion to be inadequate because it was not clear that the examiner considered the Veteran’s competent lay statements regarding his reported symptoms since his involvement in the motor vehicle accident in service. More specifically, the Veteran had stated that he lost consciousness from the accident and had diminished short-and long-term memory, headaches, and occasional disorientation to time and place since the accident in service. As such, the Board remanded for an addendum medical opinion from the April 2019 examiner, or a suitable substitute, to answer the following specific questions: Does the Veteran have a current traumatic brain injury (TBI) or any other type of brain injury or brain disorder? If the Veteran has a current TBI, or any other type of brain injury or brain disorder, is it at least as likely as not (i.e., probability of 50 percent or greater) that it is related to the Veteran’s service? The Board also advised that when answering these questions, the examiner must review and consider the lay statements of record, to include the Veteran’s reported history of symptoms such as memory problems, headaches, and disorientation since his in-service car accident, as well as his assertions of losing consciousness in the aftermath of the in-service car accident. The examiner was to also note that the lack of a diagnosed traumatic brain injury in service cannot serve as the sole basis for a negative finding. In November 2019, an addendum opinion was obtained from the same examiner. The examiner again rendered a negative opinion and as rationale, stated there was no evidence to support loss of consciousness, alteration of mental states, or loss of memory events as required for VA rating purposes. There are no medical records to support the claimed TBI. Clarification was sought, and in July 2020, the same examiner provided a second addendum opinion. This time, the examiner stated the Veteran does not have a current TBI; that there was no treatment record for this accident; and, that although the Veteran claimed he lost consciousness, upon review of the claims file, there is no corroboration of loss of consciousness, alteration of consciousness, and post traumatic amnesia. The Board finds the examiner’s November 2019 and July 2020 addendum opinions do not comply with the Board’s August 2019 remand, as it is still unclear whether the examiner considered the Veteran’s reported history of symptoms such as memory problems, headaches, and disorientation, as well as his assertions of losing consciousness in the aftermath of the in-service car accident. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As a result, the Board finds that both the November 2019 and July 2020 addendum opinions are inadequate. On remand, a new examination shall be obtained from a different examiner. The matters are REMANDED for the following action: Schedule the Veteran for a VA TBI examination to be conducted by one of the four designated specialists (physiatrist, psychiatrist, neurologist, or neurosurgeon). Any necessary testing or studies shall be conducted. The examiner must review the record and should note that review in the report. After reviewing the record, the examiner must respond to the following questions: • Does the Veteran have a current traumatic brain injury (TBI) or any other type of brain injury or brain disorder? • If so, (i.e. the Veteran does have a current TBI, or any other type of brain injury or brain disorder), is it at least as likely as not (i.e., probability of 50 percent or greater) that any identified TBI, or any other type of brain injury or brain disorder, had its onset during active service, to include the documented in-service motor vehicle accident and associated head trauma. In answering the questions, the examiner must review, consider, and specifically comment on the lay statements of record, to include the Veteran’s reported history of symptoms such as memory problems, headaches, and disorientation since his in-service motor vehicle accident, as well as his assertions of losing consciousness in the aftermath of the in-service motor vehicle accident. The Veteran is competent to describe any symptoms he may have experienced since service discharge, particularly symptoms of residuals of a traumatic brain injury. The examiner should also note that the lack of a diagnosed traumatic brain injury in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. (Continued on the next page)   Lastly, the examiner is asked to provide a rationale that explains the reasons behind any opinions expressed and conclusions reached. N. RIPPEL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Jiggetts 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.