Citation Nr: 21021248
Decision Date: 04/12/21	Archive Date: 04/12/21

DOCKET NO. 12-17 467A
DATE: April 12, 2021

REMANDED

Entitlement to service connection for a traumatic brain injury (TBI) is remanded.

REASONS FOR REMAND

The Veteran served in the Alabama Army National Guard (ARNG) from May 1956 to May 1966.  He had inactive duty for training (INACDUTRA) in June 1963 and September 1963.

This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2010 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO).

In February 2017, the Veteran and his spouse testified at a Board hearing.  The transcript of the hearing has been associated with the record.

The Board remanded this case in June 2017.  In a November 2019 decision, the Board denied the claim of service connection for TBI.  The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court), which vacated the Board’s November 2019 decision in a November 2020 Order.  In an accompanying Joint Motion for Remand (JMR), the parties agreed that the Board failed to ensure substantial compliance with its June 2017 remand instructions.

The parties agreed that the April 2018 VA addendum opinion fails to comply with the Board’s June 2017 remand instructions that required the examiner to address the nature and etiology of the Veteran’s headaches.  The April 2018 examiner only offered an opinion that “the noted injury and ear residuals” are less likely than not related to service but did not address the nature and etiology of the Veteran’s headaches.  Also, the Court noted the April 2018 opinion did not address the findings in the December 2009 VA medical examination report that diagnosed tension headaches and a cognitive disorder as associated with residuals of head injury and right ear injury.  Therefore, the Board finds that an addendum medical opinion is needed to address these deficiencies prior to readjudicating the claim.

The matters are REMANDED for the following action:

Obtain an addendum opinion from an appropriate clinician.  The relevant evidence in the file, including a complete copy of this remand and the JMR, must be made available to the examiner.  The necessity of an in-person examination is left to the examiner’s discretion in light of the global COVID-19 pandemic.

The examiner is asked to address the following:

a) Whether the Veteran’s headaches are at least as likely as not related to his June 1964 injury while in the line of duty resulting in a laceration on his right temple.

b) What is the etiology of this Veteran’s headaches, as opposed to headaches in general.  Is this etiology inconclusive, partially understood, or conclusive?

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A detailed explanation is required to support the answer to each question.

 

 

R. FEINBERG

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	S. Costa, 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.