Citation Nr: 21016176 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 14-28 338A DATE: March 22, 2021 REMANDED Entitlement to service connection for a psychiatric disorder. Entitlement to service connection for a foot disorder other than pes planus. REASONS FOR REMAND The Veteran served on active duty from April 1973 to May 1976. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In June 2016, the Veteran and L.F. testified at a Board videoconference hearing before the undersigned Veterans Law Judge (VLJ). 1. Entitlement to service connection for a psychiatric disorder. Remand is required for an adequate VA opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records). At the June 2016 hearing, the Veteran stated that he self-treated his depression with alcohol following service, which ultimately led to his homelessness. The Veteran was provided with a VA examination in October 2020. The examiner determined that the Veteran’s mental health condition was less likely than not due to his active service as there was no consistent treatment or complaints of depression until 2011 or 2012. The examiner also noted a social work assessment that stated that the Veteran had been depressed since 2002 and that his depression worsened in 2011 when he was forced to resign. The Board finds this opinion to be inadequate as the examiner’s rationale rested largely upon the lack of documentation of symptoms in medical treatment records and the examiner also failed to address the Veteran’s lay statements. 2. Entitlement to service connection for a foot disorder other than pes planus. Remand is required for an adequate VA addendum opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board is obligated by law to ensure that the RO complies with its directives. Stegall, 11 Vet. App. at 271. RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. Dalton, 21 Vet. App. at 39-40. In the remand, the Board directed the examiner to address the June 1973 STR noting foot pain, the March 2012 VA examination, and the January 2017 VA examination. In a September 2020 VA examination, the examiner determined that the Veteran’s foot conditions were less likely than not related to service. The examiner noted that the Veteran was diagnosed with pes planus on the entrance examination and determined that while the condition may have been aggravated by service, it was not caused by service. The examiner then stated that the Veteran’s other foot conditions could have been a progression of his pes planus, however no evidence of his foot conditions appeared in the Veteran’s medical treatment records until the 2000s, therefore it was difficult to determine the etiology of the foot conditions. The Board finds this opinion to be inadequate as the examiner did not provide a sufficient rationale for the opinion that any opinion required speculation. Furthermore, the examiner failed to address the above-noted pieces of evidence. As such, remand is required for an adequate VA opinion that addresses the pertinent pieces of evidence as instructed by a prior Board decision. The matters are REMANDED for the following action: 1. Provide the Veteran with an appropriate examination to determine the etiology of any psychiatric disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner is further specifically instructed not to rely exclusively on the lack of contemporaneous, in-service documentation of a mental disorder diagnosis or treatment. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed psychiatric disorder (to include depression) had its onset in, or is otherwise related to active duty service? In providing this opinion, the examiner must presume as true the Veteran’s lay statements as to his reports of experiencing depression since service. 2. Provide the Veteran with the appropriate examination to determine the etiology of his foot disabilities. The claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must determine all current diagnoses of the bilateral feet and toes other than pes planus. The examiner must expressly determine if there is hallux valgus, foot arthritis, and other disorders of the toes. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (a 50 percent or better probability) that each diagnosed foot and toe disorder (other than pes planus) had its onset in, or is otherwise related to active duty service? The examiner must address the following: 1) the June 1973 service treatment record noting reports of foot pain; 2) the March 2012 VA examination report; 3) the February 2018 private DBQ; and 4) the January 2017 VA examination report. 3. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board AK 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.