Citation Nr: 21015661 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-30 059 DATE: March 18, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) with insomnia is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1979 to October 1982. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2013 rating decision of the Department of Veteran’s Affairs (VA) Regional Office (RO). In a March 2015 rating decision, the RO treated the appeal as the outcome of a request to reopen a prior final denial. However, the Veteran submitted new and material evidence within one year of the April 2013 decision, which was readjudicated in a September 2014 rating decision denying the same issue. Within one year of that rating decision, the Veteran submitted a statement describing outstanding relevant treatment records and requesting that the rating decision be reconsidered based on the new evidence. VA readjudicated the claim in the March 2015 rating decision, and the Veteran filed a notice of disagreement and perfected the appeal. As a result, the original August 2012 claim for service connection is still pending. Beraud v. McDonald, 766 F.3d 1402, 1407 (Fed. Cir. 2014) (holding that 38 C.F.R. § 3.156(b) requires VA to “provide a determination that is directly responsive to the new submission and... until it does so, the claim at issue remains open.”) The Veteran was afforded a hearing before the undersigned Veterans Law Judge in February 2021. The transcript has been associated with the file. 1. Entitlement to service connection for an acquired psychiatric disorder to include PTSD with insomnia is remanded. The Veteran originally asserted in his August 2012 claim to benefits that his depression and other “mental health issues” are a result of the stress caused by his military occupational specialty (MOS) as an explosive ordnance disposal (EOD) technician. The Veteran later asserted that his PTSD with insomnia should be service connected as a result of his MOS. See February 2014 Statement in Support of Claim (received 2/27/2014, pp. 1). Since the Veteran is requesting benefits for symptoms of a mental health condition, the claim cannot be limited to only PTSD but rather expanded to include all the Veteran’s mental health disorders. See 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). As a result, the claim now encompasses all of the Veteran’s mental health disabilities. The Veteran was afforded a VA examination for his claimed acquired psychiatric disorder, to include PTSD, in August 2014. The examiner opined that the Veteran did have a PTSD diagnosis that conforms to the DSM-5. However, directly under that the examiner stated the Veteran’s symptoms do not meet the PTSD criteria under the DMS-5. Instead the examiner diagnosed the Veteran with depressive disorder due to another medical condition while noting a prior diagnosis of unspecified bipolar and related disorder and unspecified personality disorder. The examiner then stated that the Veteran did not have more than one mental health disability but then stated the Veteran was currently medicated for the unspecified bipolar and related disorder and unspecified personality disorder by his VA outpatient doctors. However, shortly after in November 2014, the Veteran was diagnosed with PTSD and a mood disorder based on the DSM-5 criteria in a VA mental health clinic visit note. The Veteran’s November 2014 VA outpatient records also show he was given medication to use as necessary for his anxiety. The August 2014 VA examination failed to consider all of the Veteran’s psychiatric disorders in rendering a nexus opinion. Additionally, the August 2014 examination contained contradictory statements regarding the Veteran’s diagnoses. As a result, the August 2014 examination is inadequate, and the Veteran is entitled to a new examination for a medical opinion regarding his claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007); 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). At his hearing, the Veteran identified outstanding relevant treatment records with VA mental health. The most recent VA treatment records in the file are dated in March 2015. This must also be accomplished on remand. The matters are REMANDED for the following action: 1. Obtain and associate with the file all of the Veteran’s VA mental health treatment records dated after March 6, 2015. 2. Schedule the Veteran for a VA examination for his acquired psychiatric disability with a qualified VA examiner distinct from the examiner who provided the August 2014 opinion. The examiner must review the claims file, including the lay evidence in the hearing transcript. The examination may be provided remotely give the current pandemic precautions. The examiner is asked to provide a response to the following: (a.) Identify every DSM-5 diagnosis that has been present at any time since August 2012. (b.) For each identified diagnosis, state whether it is at least as likely as not related to service, including his credibly reported fear for his life during his time as an EOD technician? (c.) For the diagnosis of PTSD specifically, is the credibly reported fear for his life during his duties as an EOD technician sufficient to meet Criterion A? If yes, is this stressor the basis of any diagnosed PTSD? Provide a thorough explanation to support all opinions. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Associate Counsel, S. Conti 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.