Citation Nr: 21014675 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 20-23 963 DATE: March 15, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as borderline personality, adjustment disorder to include suicidal ideation, and bipolar disorder is remanded. Entitlement to service connection for tinea versicolor is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1987 to February 1990. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2018 rating decision from a Department of Veteran’s Affairs (VA) Regional Office (RO) denying service connection for the Veteran’s claimed borderline personality disorder, adjustment disorder to include suicidal ideation, and bipolar disorder. In February 2021, a virtual hearing was held before the undersigned Veterans Law Judge. This decision is being made under the “one-touch” program. A transcript of the hearing will be associated with the claims file at a later time. 1. Entitlement to service connection for an acquired psychiatric disorder, claimed as borderline personality, adjustment disorder to include suicidal ideation, and bipolar disorder A brief description of the Veteran’s in-service trauma is included below. In October 2017, the Veteran submitted a claim for an adjustment disorder, bipolar disorder, and borderline personality disorder. In July 2018, VA denied entitlement to service connection for “adjustment disorder (now claimed as all mental health to include suicidal ideation),” bipolar disorder, and borderline personality disorder. The Veteran disagreed with the decisions and perfected this appeal. The Board has rephrased the issue as stated above. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). The Veteran claims his current mental health disabilities began in service as a result of physical and sexual assault during active duty. In the Veteran’s May 2020 VA Form 9 he states he was physically assaulted during a “hazing ritual for crossing the Equator.” The Veteran further stated he was pulled naked out of the shower before being “beaten and humiliated” in front of his peers. The abuse continued through his tour of duty and he asserts the stress from such treatment manifested into his current mental health disorders. No VA examination has been provided for this claim. The Board finds that the duty to assist is triggered and a VA examination is needed for these claims. Consistent with the VA's duty to assist, under McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), a VA medical examination must be provided when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The claims record confirms the Veteran has been diagnosed with and is actively seeking treatment for his currently diagnosed mental health conditions. See VA mental health treatment center notes (CAPRI records received 9/16/2019). This is competent evidence of a current disability. In the Veteran’s May 2020 VA Form 9 he asserts these mental health conditions began in service as a result of a physical and sexual assault while on active duty. When a claim is based on an in-service personal assault, evidence from sources other than the Veteran’s service treatment records may substantiate the Veteran’s account of the stress-inducing incident. See 38 C.F.R. § 3.304(f)(5). As a result, the Veteran’s assertions are credible and competent evidence of an in-service stressor event. The Veteran’s testimony of onset of symptoms in service and continuing to the present create an indication that that the disability may be associated with the veteran’s service. Furthermore, there is insufficient competent medical evidence of record to provide insight into the connection between the Veteran’s current mental health disorders and active service. This meets the McLendon threshold and a remand is needed for a VA examination and an etiology opinion. 2. Entitlement to service connection for tinea versicolor The Veteran first submitted a claim for “tinea versicolor” in October 2009. The RO issued a rating decision in December 2009 denying service connection. The Veteran did not appeal, and that decision became final. The Veteran then submitted a new claim for a “fungus (rash) on back” condition in October 2017. The RO issued a rating decision in April 2018 denying service connection for “tinea versicolor (now claimed as fungus, rash on back).” The Veteran disagreed and timely submitted a notice of disagreement for tinea versicolor in June 2018 however no statement of the case (SOC) was ever issued. As a result, the Board must remand the claim to the agency of original jurisdiction so that an SOC may be issued. See Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records relevant to the Veteran’s mental health and skin. 2. Send the Veteran notice required for PTSD claims based on personal assaults and allow time for a response. Then, attempt to corroborate the Veteran’s in-service stressors based on personal assault, including being pulled from a shower naked and assaulted. If more details are needed, contact the Veteran to request the information. 3. Schedule the Veteran for a VA examination for his mental health conditions. Given pandemic precautions, the examination may be accomplished remotely and need not be in person unless deemed necessary by the examiner. The examiner must review the claims file, including the hearing transcript. The examiner is asked to provide a response to the following: (a.) Identify all diagnoses conforming to the DSM-5 that have been present at any time since October 2017. Please also rule in or out a diagnosis of PTSD. (b.) For each identified diagnosis, please state whether it is at least as likely as not related to service, including the credibly reported physical and sexual assault. The examiner must address the Veteran’s lay assertions of the traumas he experienced in service. Provide a rationale to support the opinion(s). (Continued on the next page)   4. Send the Veteran and his representative a statement of the case that addresses the issue of tinea versicolor. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.