Citation Nr: 21023289 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-00 047 DATE: April 20, 2021 ORDER As new and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, paranoid; anxiety disorder versus bipolar disorder and schizoaffective disorder versus insomnia, the appeal to this extent is allowed. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. In the last final October 1998 rating decision the Regional Office (RO) denied the Veteran’s claim of entitlement to service connection for insomnia, anxiety disorder, schizophrenia and schizo-affective disorder. 2. Evidence received since the October 1998 rating decision is new and material because the evidence had not previously been submitted, is not cumulative or redundant of the evidence of record at the time of the prior rating decision, and raises a reasonable possibility of substantiating the claim of service connection for an acquired psychiatric disorder, to include schizophrenia, paranoid; anxiety disorder versus bipolar disorder and schizoaffective disorder versus insomnia. CONCLUSIONS OF LAW The October 1998 rating decision denying the Veteran’s claim of entitlement to service connection for insomnia, anxiety disorder, schizophrenia and schizo-affective disorder is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been submitted since the last denial in October 1998 and the claim of service connection for insomnia, anxiety disorder, schizophrenia and schizo-affective disorder is reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1975 to December 1980 and from June 1984 to August 1991. The Board notes that although the Veteran indicated in a June 2015 VA Form 9 that he requested a Board hearing with respect to his claim, in a February 2016 correspondence, the Veteran withdrew his request for a Board hearing. In March 2021, the Board sent the Veteran a letter clarifying whether he would like a new representative. As the Veteran did not respond, The American Legion remains his representative. Issues 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, paranoid; anxiety disorder versus bipolar disorder and schizoaffective disorder versus insomnia. VA law provides that a claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). When making a determination as to whether received evidence meets the definition of new and material evidence, the Board should take cognizance of whether that evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). The RO in a June 1995 rating decision denied service connection for a bipolar disorder based on the determination that it neither occurred in nor was caused by service and was first diagnosed in August 1994. The RO also determined that the evidence did not show that the bipolar disorder was directly related to the service-connected gastritis, alleged to be caused by stress in service. In an April 1998 rating decision the RO determined that new and material evidence was not submitted to reopen the Veteran’s claim of entitlement to service connection for bipolar disorder. In an October 1998 rating decision the RO denied the Veteran’s claim of entitlement to service connection for insomnia, anxiety disorder, schizophrenia and schizo-affective disorder based on the determination that service treatment records are silent of any treatment or diagnosis of anxiety disorder, schizophrenia, and a schizo-affective disorder during service. The RO noted that insomnia is a symptom or abnormal finding and not a ratable entity without an established diagnosis. The Veteran did not perfect an appeal of the above decision and additional new and material evidence was not received within a year following the decision. See 38 C.F.R. § 3.156(b). The decision is final and binding based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.302, 20.1103. The evidence added to the record since the last final rating decision includes the Veteran’s April 2013 notice of disagreement whereby the Veteran contended that he could not seek mental health treatment during service as he would lose his security clearance. He stated that right after service he started receiving treatment at the Energy Basic Clinic in Hanna, Wyoming, however his records were destroyed by fire. In a December 2012 statement the Veteran’s spouse indicated that when the Veteran came home from service in Germany, he was very moody and paranoid. He reported his clearance was getting on his nerves and his stress level was getting stronger. Thus, the evidence received is neither cumulative nor redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claim of service connection for an acquired psychiatric disorder. The credibility of the evidence is presumed for the purposes of reopening the claim of service connection for an acquired psychiatric disorder. REASONS FOR REMAND Issue 2: Entitlement to service connection for an acquired psychiatric disorder. In the December 2014 Form 9 Appeal the Veteran indicated that his psychiatric symptoms began during service and he could not seek treatment due to his security clearance. He stated that he has been diagnosed with bipolar disorder, anxiety disorder, and posttraumatic stress disorder (PTSD). The Veteran’s DD 214 Forms show that his military specialties included being a Pershing missile crewmember, personnel administrative specialist, personnel actions specialist, and telecommunications center operator. In March 2015 the Veteran’s representative reiterated that the Veteran contends he experienced symptoms of a psychiatric disorder during service but did not seek treatment as he feared losing his security clearance. Treatment records show the Veteran’s psychiatric disorder has been variously diagnosed including as manic depressive disorder, bipolar disorder, schizophrenia, and anxiety disorder. See, e.g., medical records dated in August 1994, January 1995, March 1995, and August 1996. More recent treatment records in July 2019 include panic disorder and bipolar disorder among the Veteran’s active problems. There is an opinion from March 1995 whereby the doctor opined that the Veteran’s stress in service that caused his stomach disorder also caused his depressive disorder. Notably, the Veteran is service connected for gastritis duodenitis. Thus under the circumstances of this case, a VA examination is warranted to determine the nature and etiology of the Veteran’s psychiatric disorder. On remand, the Veteran also should be asked to provide information regarding any claimed in-service stressors. Lastly, in April 2013 the Veteran noted that he was currently seeing a psychiatrist at the Lakeland VA clinic. As it is unclear whether there are any outstanding VA treatment records from the Lakeland VA clinic, on remand an effort needs to be made to obtain them. The matter is REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any outstanding VA medical records, including from the Lakeland VA clinic. All attempts associated therewith should be memorialized in the Veteran’s claims file. 2. Contact the Veteran and request that he provide information regarding the stressors on which he bases his claim for PTSD, to include descriptions, along with dates, locations, and units he was with. 3. Afterwards, and after reviewing the record and a copy of this remand, undertake the necessary development to attempt to corroborate the stressors with the Joint Services Records Research Center (JSRRC).   4. Schedule the Veteran for a VA psychiatric examination. After reviewing the claims folder, conducting all necessary tests, and examining the Veteran the examiner is asked to do the following: a.) Identify/diagnose all current psychiatric disorders per the DSM V criteria, to include whether the Veteran meets the criteria for PTSD. b.) If the Veteran is diagnosed with PTSD per the DSM V criteria, the examiner must provide an opinion as to whether the PTSD symptoms are related to a verified inservice stressor. c.) For any psychiatric disorder other than PTSD the examiner must opine whether it is at least as likely as not (50 percent or better probability) that it is related to an in-service injury, event, or disease. d.) Provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any acquired psychiatric disorder was (a) caused or (b) aggravated by the Veteran’s service-connected gastritis duodenitis.   In rendering the opinions the examiner is asked to consider the Veteran’s contentions that he experienced symptoms of a psychiatric disorder during service but did not seek treatment as he feared losing his security clearance. For all opinions rendered, the examiner should explain the rationale. If the examiner is unable to provide an opinion, he or she should explain why. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Mac, 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.