Citation Nr: 21011818 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 16-06 908 DATE: March 2, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder is denied. FINDING OF FACT 1. The Veteran has not established that the claimed in-service stressor occurred. 2. The Veteran was first diagnosed with PTSD in 2010 approximately 39 years after his discharge from active duty. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1101,1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125, 4.130 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1969 to May 1971. Entitlement to service connection for an acquired psychiatric disorder. This matter comes to the Board of Veteran’s Appeals (Board) following a June 2020 remand. The appeal originated from a March 2013 decision of the Regional Office (RO), which denied service-connected compensation for an acquired psychiatric disorder. As the Board explained in a previous September 2018 remand, several decision documents issued by the RO describe the issue in this appeal as whether to reopen a previously denied claim for service connection for an acquired psychiatric disorder. The Board found in the June 2020 decision that there was no need for new and material evidence and the Board could properly consider the psychiatric claim on its merits. In April 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a travel Board hearing. A transcript of that hearing is of record. When an appeal is remanded, the appellant obtains a right to compliance with the Board’s remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The RO has complied with the Board’s instructions set forth in the September 2018 and June 2020 remands. In September 2018, the Board remanded the claim in order to request records at the VA Medical Center in Houston, Texas dating back to 1972. In addition, the Board requested that the RO attempt to verify the Veteran’s TAD deployments, in part by making an appropriate request for the Veteran’s pay records from the Defense Finance and Accounting Service (DFAS). When the Veteran’s claim was returned to the Board in June 2020, the RO had accomplished some, but not all, of the requested development. At this time, however, the RO has fully complied with the remand development. Documentation has been associated with the Veteran’s claims file indicating that the RO contacted the VA Medical Center in Houston Texas and received a response that they do not have medical records associated with this Veteran dating back to 1972. In addition, the RO accomplished the various inquiries suggested with regard to attempting to locate pay records. A response dated June 24, 2020 from DFAS indicates that there are no W2 records available before 1975. The RO submitted the Veteran’s ID number to look for files and in July 14, 2020 the response indicated that there are no active duty records and no reserve records prior to 1982. Accordingly, the RO has fully complied with the remand orders. With regard to the Veteran’s claim, the Veteran contends in his hearing testimony and written statements that he developed posttraumatic stress disorder (PTSD) during his participation in highly classified covert operations in Vietnam during his active duty service. The available service medical and personnel records appear to contradict this claim. Service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). In order to prevail on a PTSD claim, the record must reflect credible supporting evidence that the claimed in-service stressor actually occurred. The Veteran at all times has maintained that his stressor events occurred in Vietnam. The Board finds that there is no persuasive evidence that the Veteran was in Vietnam. For that reason, the Veteran’s claim for PTSD must be denied. The available service medical and personnel records do not support that the Veteran was in Vietnam. Between December 1970 and May 1971, service medical records include progress notes indicating that the Veteran was treated for rhinitis at Camp Lejeune, North Carolina in January 1971, which overlaps with the time period the Veteran identified in testimony that he was in Vietnam. All of his assignments listed in the service personnel files appear to have been in the continental United States. The Veteran’s files are rather extensive and there are no documents or entries that suggest the Veteran ever left the United States. A review of the Veterans personnel records and service treatment records in the claims file shows that the stressful events reported by the Veteran are not consistent with the places, types and circumstances of the Veteran’s service reflected in the record. Service personnel records indicate that all of the Veteran’s assigned duty stations between May 1969 and May 1971 were in the continental United States. In his hearing testimony, the Veteran said he was in Vietnam between December 1970 and April 1971. But his service treatment records include progress notes indicating that he was treated for rhinitis at Camp Lejeune, North Carolina, in January 1971. To help decide the Veteran’s claim, the RO obtained a command history of the unit to which the Veteran was assigned. According to this chronology, the unit was stationed at Camp Lejeune at the relevant time. Although stamps on the initial pages of the command chronology indicate that the document was once classified, there is no reference to Vietnam or to covert operations. The Veteran has submitted letters from treating VA mental health professionals, which indicate that he has chronic PTSD and that his symptoms are related to service. The letters, both dated September 2015, are from a psychologist and licensed clinical social worker and from a psychiatrist. Both letters also assume that the Veteran served in Vietnam, a factual premise which is inconsistent with the record. The weight of the evidence of record does not demonstrate that the Veteran was in Vietnam during his active service. The Board is not able to grant the Veteran’s claim for PTSD because after diligent efforts, the record does not contain credible supporting evidence that the claimed in-service stressor actually occurred. Establishing the Veteran’s claim for a psychiatric disorder through direct service connection requires a current diagnosis and proof of actual direct causation with an in-service disease or injury. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181(1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). A review of the Veteran’s service treatment records (STR’s) reveals that the Veteran was not treated for any psychiatric disorder during service and his psychiatric condition was normal. Accordingly, the requirements for direct service connection are not met. Service connection requirements through chronicity are set forth in the VA regulations. Chronic diseases in general are enumerated “chronic disease” listed under 38 C.F.R. § 3.309 (a). Establishing chronic disease in this way requires a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331(Fed. Cir. 2013). Attempts to establish evidence of chronicity in the Veteran’s file have not been successful. At his hearing, the Veteran testified that he experienced symptoms of his current mental illness shortly after his discharge from active duty: “I got out of the Marines and my wife knew something was wrong with me, you could tell. I went to the VA in Houston, Texas in 1972 and... I went to the psychiatrist.... [and] he sat down and talked with us and said... you’ve been through a war here, you’re supposed to feel like this.” Requests were made to locate the 1972 Houston VAMC records and the facility responded that they did not have any records for this Veteran. The Veteran attended his initial VA PTSD evaluation many years after his separation from service in 1971. On November 2, 2010, the Veteran was diagnosed with chronic PTSD at this initial exam, along with a report that the Veteran was hospitalized for psychiatric reasons in May 2010 for seven days and August 2020 for four days. The Veteran’s existing medical treatment records associated with the claims file similarly do not support a finding for chronicity. The weight of the evidence of record does not demonstrate mental illness manifestations sufficient to identify the disease entity over time, and there is not sufficient observation over time to establish chronicity. The Veteran’s medical treatment records associated with the claims file are consistent with this conclusion. The Board must deny the claim on appeal for entitlement to service connection for a mental illness through chronicity. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements and those of his wife in support of his claim. The preponderance of the evidence does not support that the Veteran was in Vietnam and does not support that he was treated during service or shortly thereafter for any similar symptoms.   The benefit of the doubt doctrine is not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.