Citation Nr: 21013671 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 18-38 312 DATE: March 10, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1988 to July 1991 with service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board denied the claim in September 2019, and the Veteran appealed the decision to the United States Court (Court) of Appeals for Veterans Claims. In October 2020, the Court vacated the Board and remanded the case for readjudication. See October 2020 Court Order and Joint Motion for Partial Remand (JMR). The matter has been returned to the Board. The Veteran’s accredited representative submitted an informal hearing presentation to the Board in February 2021, arguing that the claim should be remanded to the Agency of Original Jurisdiction (AOJ) as the VA examination relied upon in the now-vacated Board decision is inadequate. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and PTSD, is remanded. Consistent with the JMR, the Board has considered whether VA’s duty to assist was satisfied with regards to the adequacy of the November 2016 VA examination in light of the discussion and findings in the JMR. It was noted that the examiner failed to address lay statements regarding symptoms and combat experiences in rendering conclusions. Upon review of the entire record, we find that this claim must be returned to the AOJ to obtain a medical examination with opinion, as the medical opinion relied upon by the Board was inadequate. It is established that the Veteran engaged in combat, but the decision ultimately found that his claimed stressors were not consistent with the circumstances, conditions or hardships of service as “[t]he stressors reported by the Veteran include financial hardship and having a special-needs child, but no stressors related to his time in-service.” The Board found no stressors related to service and did not address the Veteran’s assertion in August 2016 that he “came under direct and indirect fire” from the enemy while serving in Iraq, and “saw people getting killed” during deployment. The JMR pointed out that Board did not address favorable portions of the November 2016 VA PTSD examination wherein the examiner (1) acknowledged the Veteran’s reported combat-related stressors and opined that Appellant’s reported stressors were adequate to support a diagnosis of PTSD and (2) noted “chronic sleep impairment” as a symptom of Veteran’s depressive disorder, with the Veteran relating his sleep problems to his in-service combat experiences.   The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA psychiatric examination. The entire claims file, including the JMR and this remand, must be made available to the examiner. The opinion report should include a discussion of the Veteran’s documented mental health history and assertions and all clinical findings should be reported in detail. The examiner should respond to the following: Please identify any acquired psychiatric disorder, to include PTSD, present during the pendency of this claim. For each diagnosed acquired psychiatric disorder, is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s acquired psychiatric disorder is related to or had its onset in active duty? Please address (1) the Veteran’s August 2016 assertion that he “came under direct and indirect fire” from the enemy while serving in Iraq, and “saw people getting killed” during deployment in light of the fact that he engaged in combat, (2) the prior examiner’s acknowledgement that the reported stressors were   adequate to support a diagnosis of PTSD and “chronic sleep impairment” was a symptom of Veteran’s depressive disorder, and (3) the Veteran assertion that his sleep problems are related to in-service combat experiences. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of all lay and medical evidence of record. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. RIPPEL 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.