Citation Nr: 21020742 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-46 119 DATE: April 8, 2021 REMANDED The issue of service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty in the U.S. Navy from November 1990 to July 1992. These issues were previously before the Board. In August 2019, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. Specifically, the Board directed the AOJ to 1) obtain outstanding records of pertinent medical treatment from VA or private health providers; 2) attempt to corroborate the Veteran’s alleged PTSD stressors, which include bullying by fellow service members and witnessing a rough helicopter landing; and 3) schedule the Veteran for a VA examination to determine the nature and etiology of any current psychiatric disability, to include mixed anxiety and depressed mood and PTSD. In August 2019, the AOJ asked the Veteran to complete and return a VA Form 21-4142 to obtain pertinent medical treatment records and the Veteran returned them in September 2019. The AOJ notified the Veteran twice that medical records were requested from the private providers identified in the returned VA Form 21-4142. One private provider, however, stated that they could not locate the Veteran’s files in their system, and the second provider did not respond. In January 2020, the Veteran was afforded a VA examination for his claimed acquired psychiatric disability. Later that month, the VA Appeals Management Center (AMC) continued the previous denials in a supplemental statement of the case (SSOC) issued. In February 2020, the AOJ attempted to contact the Joint Services Records Research Center (JSRRC) to verify the Veteran’s claimed stressors, but the JSRRC was temporarily closed from March 2020 due to the COVID-19 pandemic. In July 2020, the AOJ obtained up to date VA Medical Center medical treatment records, and in August 2020, informed the Veteran that private medical treatment records could not be obtained. In the same month, the JSRRC Coordinator formally found that there was insufficient information to corroborate the Veteran’s allegation of PTSD during service from November 1990 to July 1992. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. The issue of service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) As discussed above, in August 2019, the Board directed the AOJ to obtain a medical opinion identifying each current psychiatric diagnosis found to be present since June 2015 with a detailed rationale for all opinions. The Veteran was afforded a VA examination in January 2020. The examiner opined that the Veteran did not have a mental disorder that conformed with DSM-5 criteria despite noting that the Veteran was prescribed medication for his “dreams.” The examiner also opined that the Veteran’s symptoms did not meet the diagnostic criteria for any mental health condition “that can be logically related to events occurring during his military service.” The examiner did not discuss the June 2015 private medical treatment record that diagnosed the Veteran as having adjustment disorder with depressed mood using the DSM-5 criteria despite the Board’s specific directions to identify each diagnosis found to be present since June 2015. There is no rationale supporting the January 2020 VA examiner’s opinion that the Veteran did not have a mental disorder that conformed with DSM-5 criteria. Compliance with remand directives by the originating agency is not optional or discretionary. The Board errs as a matter of law when it fails to ensure remand compliance. See Stegall v. West, 11 Vet. App. 268 (1998). Also, when a VA examination is provided or when a VA opinion is obtained, the VA must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matter is REMANDED for the following action: 1. Attempt to corroborate the Veteran’s alleged PTSD stressors, which include bullying by fellow service members in recruit training and witnessing a rough helicopter landing aboard ship. If the information provided by the Veteran is insufficient, attempt to obtain necessary information from the Veteran and document such attempts. 2. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of any current psychiatric disorder, to include PTSD. The examiner should review the virtual file. Attention is called to the file of service treatment records that includes mental health assessments in late November 1990 and a July 1992 discharge physical examination report, to lay statements posted to the file in April 2014, and the file of private treatment in October 2014, February 2015, and September 2017. The examiner is to address the following: (a) State whether an acquired psychiatric disability is currently present. If the examiner disagrees with a diagnosis already established in the medical records, such as the February 2015 and June 2015 diagnoses of adjustment disorder with depressed mood, he/she should so state and explain why. (b) Whether it is at least as likely as not (50 percent or greater probability) that an acquired psychiatric disability, if diagnosed, manifested during, or is otherwise related to the Veteran’s period of active service, to include alleged bullying and helicopter crash during service. Even if verification cannot be shown, comment from a medical or psychological perspective whether the reports of the incidents are credible and whether they are causes for any current disability. Rationales for all opinions are to be provided. All pertinent evidence, including both lay and medical, should be considered. The examiner may not rely on the absence of complaints, treatments, or diagnoses in the service treatment records. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Yun, 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.