Citation Nr: 21013559 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 18-35 893 DATE: March 9, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, unspecified trauma and stressor related disorder, and posttraumatic stress disorder (PTSD), is remanded. Entitlement to an earlier effective date prior to September 28, 2016, for entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from February 1992 to August 1992, from October 1992 to May 1993, and from March 2007 to November 2007. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Board issued a decision denying the Veteran’s service connection claim for an acquired psychiatric disorder and an earlier effective date for TDIU. The Veteran appealed the Board’s denial decision to the United States Court of Appeals for Veterans Claims (CAVC), resulting in an October 2020 Joint Motion for Partial Remand (JMPR), which vacated the December 2019 Board decision as it pertained to the service connection claim for an acquired psychiatric disorder and an earlier effective date for TDIU, and remanded for re-adjudication consistent with its decision. Regrettably, the Board finds that a remand is necessary, prior to re-adjudication of the claims. As an initial matter, the Board notes that a claim for service connection for a mental disability may encompass claims for service connection of any medical disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board has recharacterize the issue as shown on the title page, which will encompass all diagnosis/treatments of record, to include bipolar disorder, unspecified trauma and stressor related disorder, and PTSD. 1. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, unspecified trauma and stressor related disorder, and PTSD, is remanded. A review of the record reflects that a community mental health treatment record shows treatment for the Veteran’s bipolar disorder in January 2000, with a history of the condition dating back to 1989, suggesting that the Veteran had a psychiatric disorder prior to entering active duty service. Additionally, in a July 2017 VA medical opinion, the examiner suggested that the Veteran’s psychiatric disorders, to include unspecified trauma and stressor related disorder and bipolar disorder, were incurred before the Veteran joined the service as attributable to his childhood abuse and/or was a genetic/organic condition. See C&P Exam, July 2017. Furthermore, in an April 2018 private medical opinion, the examiner opined that the Veteran’s mental problems, to include PTSD, was preexisting to his military service and was aggravated more than normal. See Private treatment record, April 2018. Therefore, in agreeance with CAVC, the Board finds that the record has raised the question as to whether the Veteran had a psychiatric condition prior to service that was aggravated by such service, and thus, consideration of the presumption of soundness must be addressed. As such, the Board finds that a remand is necessary to obtain an addendum VA medical opinion to adequately address the theory of presumption of soundness, prior to re-adjudication of the claim. 2. Entitlement to an earlier effective date prior to September 28, 2016 for entitlement to a TDIU due to service-connected disabilities is remanded. The Board notes that as development of the Veteran’s disability claim before the Board may have an impact on the Veteran’s TDIU claim, the Board finds these issues to be inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the Board will defer adjudication of the inextricably intertwined TDIU claim at this time. The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for any acquired psychiatric disorder and obtain any outstanding records and associate them with the Veteran’s claims file. 2. After associating all newly acquired records with the claims file, provide the Veteran with an addendum VA medical opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s acquired psychiatric disorders. The entire claims file, including a copy of this remand, must be made available to the examiner, and note review of the record in the examination report. Any indicated tests or studies should be performed, and all material relevant evidence should be discussed. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. The Veteran should be scheduled for another examination if deemed necessary by the person providing the addendum report to address the following: (a) Identify and clearly describe all diagnoses related to the Veteran’s acquired psychiatric disorder, to include bipolar disorder, unspecified trauma and stressor related disorder, and PTSD. (b) Opine whether there is clear and unmistakable (obvious or manifest) evidence that any of the Veteran’s psychiatric disorders existed prior to his entrance into any period of active duty service. Please note: the examiner must opine as to all active duty periods; as well as, discuss the July 2017 VA medical opinion and the April 2018 private medical opinion suggesting/noting a preexisting condition. (b) If so, opine whether there is clear and unmistakable (obvious or manifest) evidence that the preexisting psychiatric disorder(s) did NOT undergo an increase in severity beyond the natural scope of the disability during any period of the Veteran’s active duty service. Please note: the examiner must discuss the July 2017 VA medical opinion and the April 2018 private medical opinion. (c) If not, and the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not (50 percent or greater probability) related to a contended in-service stressor. Please note: If a diagnosis of PTSD is not found, the examiner must explicitly state so, and provide discussion/opinion on the determination in change of diagnosis from that reflected in the April 2018 private examination. (d) If not, and for all other acquired psychiatric disorders diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not (50 percent or greater probability) had its onset during any period of the Veteran’s active duty service, or is otherwise etiologically related to his active duty service, to include any contended in-service stressor. (e) The examiner is asked to consider and reconcile any conflicting medical evidence or opinions of record. (f) Any opinion should include a detailed rationale. The examiner should consider the entire claims file, and discuss the Veteran’s lay statements regarding the nature, onset, and chronicity of symptoms. The examiner is advised that the Veteran is competent to report symptoms, and that his reports must be considered in formulating the requested opinion. (Continued on the next page) (g) If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rational for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Hodges, 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.