Citation Nr: 21012303 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 07-28 524 DATE: March 4, 2021 REMANDED Entitlement to service connection for vision loss is remanded. Entitlement to service connection for a headache disorder is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from July 1967 to July 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2006 rating decision by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). These matters were previously before the Board in August 2009, March 2011, and March 2019. In August 2009, the headache disorder issue was remanded in order to both obtain additional private and VA treatment records and ensure that all relevant documents were translated to English. In the March 2011 remand, instructions required that additional attempts be made to obtain both private and VA treatment records. Additionally, a statement of the case (SOC) was to be provided addressing the vision loss issue under Manlincon v. West, 12 Vet. App. 242 (1999). Following these actions, VA examinations were to be completed addressing the Veteran’s headache disorder and loss of vision. Most recently, in March 2019, the matters were again remanded in order to obtain addendum medical opinions. In November 2019 and November 2020, addendum opinions were obtained addressing whether the Veteran’s headache disorder and vision loss are at least as likely as not related to active service. The matter is again before the Board. Vision Loss Regarding the issue of vision loss, substantial compliance with the Board’s prior remand orders is demonstrated. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). However, additional remand is nonetheless warranted. In December 2020, a supplemental statement of the case (SSOC) was provided. It was noted that treatment records from VA medical centers (VAMCs) in San Juan and Dallas through November 2020 and October 2020 respectively were reviewed and considered. However, such updated records have not been included in the Veteran’s claims file. Rather, the claims file only includes VA treatment records from both San Juan and Dallas through November 2019. Accordingly, complete VA treatment records must be associated with the claims file upon remand, to permit the Board to consider all relevant evidence. Headache Disorder Regarding the issue of headache disorder, the Agency of Original Jurisdiction (AOJ) did not substantially comply with the March 2019 remand directives. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. As such, another remand is warranted. In the March 2019 remand, the Board specifically instructed that in providing an opinion as to whether it is at least as likely as not that any current headache disability began during active service, the examiner must consider the Veteran’s contentions of continued symptomatology following his in-service injury, as well as his in-service complaint of headaches in February 1968. If the examiner rejects the Veteran’s reports, she/he must provide an explanation for such rejection. However, in the November 2019 addendum opinions, the examiner failed to consider the Veteran’s contentions of continued symptomatology. Furthermore, the examiner did not provide a new opinion addressing the issue, but rather, stated that she disagreed with the December 2018 diagnoses and opinion and that she agreed with the January 2019 opinion and had nothing to add to it. As such, this is inadequate. Additionally, further clarification is required as to the Veteran’s current headache diagnoses. In the December 2018 examination, the Veteran was afforded separate diagnoses for migraines and positional headaches. However, the November 2019 examiner noted that she disagreed with this assessment and diagnosed the Veteran solely with “history of skull osteoma post surgeries – headache disorder residual.” Accordingly, on remand, the examiner should clarify the Veteran’s current headache-related diagnoses. The matters are REMANDED for the following action: 1. Obtain updated, complete VA treatment records. 2. Obtain an addendum opinion regarding the etiology of the Veteran’s headaches. The entire claims file must be made available to and reviewed by the examiner. A physical examination may be requested at the discretion of the reviewer. The examiner must identify all currently diagnosed headache disorders, and for each, must opine as to whether it is at least as likely as not that any current headache disability began during active service. The examiner must specifically address the Veteran’s contentions of continued symptomatology following his in-service injury and his in-service complaint of headaches in February 1968. If the examiner rejects the Veteran’s reports, he or she must provide an explanation for such rejection. 3. Then, readjudicate the claims. If the benefits sought remain denied, the Appellant should be provided a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.P. Faris 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.