Citation Nr: 21012071 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 15-36 912 DATE: March 3, 2021 REMANDED The issue of service connection for residuals of a head injury is remanded. The issue of service connection for an acquired psychiatric disorder, claimed as depression, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1, 1971, to August 4, 1971. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2014 rating decision. In January 2021, the Veteran testified at a Board virtual hearing; a transcript of the hearing is associated with the claims file. 1. The issue of service connection for residuals of a head injury is remanded. 2. The issue of service connection for an acquired psychiatric disorder, claimed as depression, is remanded. The Veteran contends that he has residuals of a head injury and a psychiatric disorder claimed as depression that began during his brief period of active duty service. In written statements and testimony, he described drill instructors shoving and hitting recruits from the first day of basic training and “making an example of” the Veteran by the third day. He described being shoved into a brick wall with his head hitting the wall first, a drill sergeant slamming his head on the floor in the barracks, or being hit in the back or his head with a fist or an object. He reported that he received treatment at Parris Island for a head injury and was evaluated and treated for depression, including at the Charleston Naval Hospital, while on active duty. He indicated that at separation from service he was told to seek follow-up treatment but he began work as a U.S. Merchant Marine and was sent to sea. In March 2014 correspondence, he stated that he “then fell on the ship and the injury came back, and with it, depression. I then went to the Public Health Hospital for depression and head injury.” He added that medical personnel “told me I had this before I went back to sea.” He asserts that he still gets intermittent headaches and has experienced depression since his military service. In a June 1971 enlistment report of medical history, the Veteran denied any history of head injury, depression or excessive worry, frequent trouble sleeping, or other psychiatric symptoms. On enlistment examination the same day, his head, face, neck, and scalp; spine; neurologic function; and psychiatric function were reported as normal on clinical evaluation. A July 1971 service treatment record reflects that the Veteran was admitted to the Marine Corps Recruit Depot (MCRD), Neuropsychiatric Evaluation Ward from July 7 to 9, 1971, with an admitting diagnosis of schizoid personality. The record details some events leading up to the admission, including the Veteran providing a false name, stating he wanted a court martial and a civilian lawyer, and reporting he had been kicked in the groin by a drill instructor and a dental officer. Mental examination revealed he was “overly sensitive about being sent to the Psychiatric Unit for evaluation”; he made “statements that the interviewer must be part of the conspiracy against him”; he tended to ramble and exhibit loose associations; and he denied any hallucinations or clear cut paranoid ideas, but he seemed “somewhat grandiose.” The discharge diagnosis was “paranoid personality” and he was sent to the U.S. Naval Hospital at Charleston for evaluation and treatment. A record of service among his service personnel records indicates that the Veteran was a patient at the U.S. Naval Hospital at Charleston from July 16, 1971, until his separation from service approximately three weeks later. Other than the summary of the Veteran’s evaluation at MCRD, no other records of evaluation and/or treatment for psychiatric problems are included with the Veteran’s service treatment records. The AOJ should attempt to obtain any records of psychiatric evaluation and treatment for psychiatric problems that may have been maintained separately from his service medical records. In addition, in April 2013, the Veteran submitted a VA Form 21-4142 (Authorization and Consent to Release Information) to allow VA to help him obtain treatment records from the U.S. Health Services Administration, Bureau of Medical Services, Public Health Service Data Center, which he believed maintained all of his treatment records from his time working as a Merchant Marine or at least from 1972 to 1992. In March 2014, the AOJ requested the identified records; however, the letter was returned to the AOJ in April 2014 as undeliverable. It appears that the AOJ did not notify the Veteran that the contact information he provided for those records was incorrect and that the records were not obtained, nor did the AOJ make any follow-up request or attempt to obtain those records. In addition, the May 2014 rating decision lists “records from the U.S. Health Services Administration, Bureau of Medical Services” among the evidence reviewed although such records are not associated with the claims file. The AOJ should attempt to obtain treatment records from the Veteran’s service and/or employment as a U.S. Merchant Marine. During the January 2021 hearing, the Veteran testified that he believed he sought treatment at the VA Hospital in Charleston, South Carolina, after separation from service but before his time as a Merchant Marine. He also believed he sought treatment at VA around 2005 and was informed he was not eligible for VA medical care. Finally, he indicated he had seen a private physician, Dr. Miner, for pain when he turns his head and for depression, although he reported he did not take any medication for depression. The AOJ should attempt to obtain any outstanding VA treatment records and private treatment records from Dr. Miner. Lastly, although the Veteran has not provided any competent medical evidence to demonstrate that he has a current disability manifested by residuals of a head injury or a current psychiatric disorder, he is competent to describe persistent or recurrent symptoms of his claimed disabilities such as headaches and depression, and he has described an event and treatment in service related to his claimed disabilities. Accordingly, the AOJ should arrange for VA examinations to determine whether any current residuals of a head injury and any current psychiatric disorder had its onset during military service or is otherwise related to military service. Parenthetically, to the extent any chronic disease such as other organic diseases of the nervous system or psychosis may have manifested within the one-year period following the Veteran’s discharge from military service, service connection for such disability on a presumptive basis is legally precluded because the Veteran did not have the requisite service of 90 days or more during a war period or after December 31, 1946. 38 C.F.R. §§ 3.307(a)(1), 3.309(a). The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain the following records: a) All records of psychiatric evaluation and/or treatment from the Marine Corps Recruit Depot at Parris Island and from the U.S. Naval Hospital in Charleston, South Carolina, which may have been maintained separately from the Veteran’s other service medical records. b) All treatment records from the Veteran’s service and/or employment with the U.S. Merchant Marines, which he previously identified as being from 1972 to 1992. c) Any records of treatment from the Charleston VA Hospital dating since August 1971. d) All private treatment records from the Veteran’s private physician, Dr. Miner. e) Any other treatment records the Veteran identifies pertinent to his claims for service connection for residuals of a head injury and a psychiatric disorder claimed as depression. 2. Schedule the Veteran for a VA examination with an appropriate clinician to evaluate the nature and etiology of his claimed residuals of a head injury manifested by intermittent headaches and pain when turning his head. Provide the Veteran’s electronic claims file and a complete copy of this Remand to the designated examiner for review. The reports of any indicated tests or studies must be associated with the examination report. The Veteran asserts he received treatment for a head injury either during the initial psychiatric evaluation during service from July 7 to 9, 1971, or during his psychiatric evaluation and treatment at the U.S. Naval Hospital following the initial psychiatric evaluation until his separation from service. Following a review of the claims file and examination, for any current disability manifested by residuals of a head injury found on examination, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such disability had its onset in service or is otherwise medically related to disease or injury in service. A medical rationale must be provided for all opinions expressed. 3. Schedule the Veteran for a VA examination with a psychologist or psychiatrist to evaluate the nature and etiology of his claimed psychiatric disorder, identified as depression. Provide the Veteran’s electronic claims file and a complete copy of this Remand to the designated examiner for review. The reports of any indicated tests or studies must be associated with the examination report. Following a review of the claims file and examination, the designated examiner should identify any psychiatric disorder(s) found on examination. For any current psychiatric disorder, including any psychosis or depression, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder had its onset during military service or is otherwise medically related to disease or injury during service. A medical rationale must be provided for all opinions expressed. In providing the requested opinion, the examiner should address the Veteran’s in-service evaluation for psychiatric impairment, diagnosed as paranoid personality prior to his transfer to the U.S. Naval Hospital for several weeks prior to separation from service. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Kirscher Strauss 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.