Citation Nr: 21023230 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 17-16 932A DATE: April 20, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to an initial compensable disability rating for traumatic brain injury (TBI), prior to July 10, 2020, and in excess of 70 percent thereafter is remanded. INTRODUCTION The Veteran served on active duty from October 1997 to March 1999, September 2004 to January 2005, and July 2008 to February 2009. In February 2020, the Veteran attended a hearing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. When this case was before the Board in April 2020, the above-noted issues were remanded for additional development. The case has since been returned for further appellate review. REASONS FOR REMAND While additional delay is unfortunate, the Board finds further development is required before the Veteran’s claims are decided. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further, a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the course of the April 2020 decision, the Board instructed the RO to initiate all indicated development to confirm the Veteran’s periods of active military service. Thereafter, the RO initiated a request through the Defense Personnel Records Information Retrieval System (DPRIS) system, as well as two requests via the Personnel Information Exchange System (PIES) to corroborate the Veteran’s periods of active service. Though the Board acknowledges the commendable efforts made by the RO, the exact periods of the Veteran’s active service remains in question. In particular, the Veteran’s representative provided a VA Form 21-4138 Statement in Support of Claim in May 2020, wherein he asserted the Veteran had active service in the U.S. Navy from January 1992 through March 1999. The Veteran’s representative also indicated the Veteran was initially diagnosed with hypertension during the alleged period of active duty on June 28, 1997. To date, the Veteran has only provided a DD-214 Certificate of Release or Discharge from Active Duty for the period of October 1997 to March 1999. However, the RO has not conducted telephone contact with either the Veteran or his representative to determine whether additional evidence exists to corroborate the Veteran’s active duty service from January 1992 to October 1997. Further, in the course of the April 2020 remand, the RO was instructed that if any requested records are deemed unavailable, the record should be annotated to reflect such and the Veteran notified. To date, a formal finding has not been prepared outlining the steps taken to obtain the records alleged to be missing by the Veteran. As such, a remand is again required in order to obtain substantial compliance with the prior remand instructions. Additionally, the Board also notes that in the course of the April 2020 remand, the RO was instructed to obtain a comorbid medical opinion from a psychiatric examiner, which addressed each and every positively affected facet noted in the Veteran’s prior TBI examinations. The Board specifically instructed the RO that each affected facet should be addressed individually. However, rather than provide the requested comprehensive opinion, the July 2020 VA examiner merely acknowledged some of the positively affected facets and indicated the current symptoms “could be” due to TBI, PTSD, or both. This opinion is insufficient, and as such, a remand is again necessary. Accordingly, this case is REMANDED for the following actions: 1. Undertake appropriate telephone development to contact the Veteran or his representative to determine the Veteran’s periods of active duty service. The Veteran and/or his representative should be notified that active service in accordance with 38 C.F.R. § 3.6, and service in the U.S. Navy Reserves or U.S. Army National Guard are not synonymous. The Veteran or his representative should be asked to detail each period of active service in accordance with 38 C.F.R. § 3.6 which the Veteran attended. Thereafter, the RO should conduct any additionally indicated development deemed necessary to verify those periods of active service. If any requested records are deemed unavailable, the record should be annotated to reflect such and the Veteran notified. 2. Additionally, the RO should obtain an addendum medical opinion from the July 2020 psychiatric examiner if available, and if unavailable, from a psychiatric examiner with sufficient expertise to provide a medical opinion. Specifically, the examiner is asked to comment on each and every positively affected facet noted in in the Veteran’s prior TBI examination reports, to specifically include: a) headaches: _____________ ; b) memory impairments: _____________; c) concentration impairments: _____________; d) impaired judgment: _____________; e) inappropriate social interaction: _____________; f) disorientation: _____________; g) visual spatial impairment: _____________; h) tinnitus: _____________; i) insomnia: _____________; j) task learning impairments: _____________. The examiner must state whether the Veteran’s manifestations are attributable to his psychiatric disorder, TBI, or whether attribution to one or the other is impossible. The examiner must also provide a complete rationale for each attribution made. If the examiner is unable to provide any required opinion, he should explain why. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Fraser, 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.