Citation Nr: 21022881 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-07 724 DATE: April 19, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1970 to May 1971. The Veteran passed away in May 2019. The Appellant is the Veteran’s surviving spouse and has been substituted as claimant. See 38 U.S.C. § 5121A. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Board recharacterized the claim for service connection for PTSD as entitlement to service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2012). In a June 2018 decision, the Board, in pertinent part, reopened the claim for service connection for PTSD but denied the claim for an acquired psychiatric disorder, to include PTSD, on the merits. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claim (Court). In a January 2020 Joint Motion for Partial Remand (Joint Motion), the parties requested that the Court vacate the portion of the Board decision that denied entitlement to service connection for an acquired psychiatric disorder, to include PTSD. In a February 2020 Order, the Court granted the Joint Motion and returned it to the Board for further action consistent with the Joint Motion. The Board subsequently remanded the claim in October 2020 for further evidentiary development. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD In its October 2020 remand, the Board, in pertinent part, requested that the RO refer the claim to a VA examiner to obtain a medical opinion addressing the claimed acquired psychiatric disorder and whether any such condition present during the Veteran’s lifetime was related to service. Although the record reflects that a VA examination was initiated in January 2021, it does not appear that a VA medical opinion was thereafter obtained or associated with the record, as instructed on remand. The RO should obtain a VA opinion. Additionally, a supplemental statement of the case (SSOC) addressing the claimed psychiatric disability has not been issued. Thus, issuance of an SSOC is necessary. 38 C.F.R. § 19.31. The matters are REMANDED for the following actions: 1. Obtain a VA opinion from an appropriate VA examiner as to the nature and etiology of any acquired psychiatric disorder, to include PTSD, that may have been present during the Veteran’s lifetime. The agency of original jurisdiction (AOJ) should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner should review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran was, and the Appellant is, competent to attest to factual matters of which they have first-hand knowledge. If there is a medical basis to support or doubt the history provided by them, the examiner should state this with a fully reasoned explanation. For each diagnosis identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, to include any symptomatology therein. The examiner should address the April 1971 service treatment record showing that the Veteran was diagnosed with a psychogenic disorder, and the April 1971 and May 1971 service treatment records documenting that he had “black outs” and passing out spells. Regarding PTSD, if there is a verified stressor, the examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor. In rendering these opinions, the examiner should also explain the significance, if any, of the gap in time between the Veteran’s military service and subsequent diagnoses. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. The AOJ should review the medical opinion to ensure compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 3. If the claim remains denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. C. Birder 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.