Citation Nr: 21023744 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 19-22 770 DATE: April 21, 2021 ORDER Service connection for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT At his March 2021 Board hearing, the Veteran provided competent and credible testimony that he was engaged in combat while in the Marines in 2003. His combat-related stressor is the basis for his currently diagnosed PTSD. CONCLUSION OF LAW The criteria are met for service connection for PTSD. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1996 to December 1996 and from May 1999 to August 2003. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2019 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). The RO characterized the Veteran’s claim as being reopened. This is incorrect. The Veteran originally claimed service connection for PTSD in October 2016. In a May 2017 rating decision, his claim was denied. In March 2018, he submitted a request for reconsideration. In May 2018, his claim was again denied. However, because the May 7, 2018 rating decision was issued within one year of the May 19, 2017 rating decision, the May 2017 rating decision never became final. After the May 2018 rating decision, the Veteran again requested reconsideration. In November 2018, he had a VA examination to evaluate his claimed PTSD. Because the November 2018 VA examination was within one year of the May 2018 rating decision, that rating decision also never became final. In January 2019, the Veteran’s claim was readjudicated for a third time and was again denied. He disagreed with this decision and submitted a Notice of Disagreement (NOD) in February 2019. In March 2019, the claim was readjudicated in a Statement of the Case, and in July 2019, the Veteran submitted a VA Form 9, Substantive Appeal. In March 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference. The claim is now before the Board. Because of this, while the January 2019 rating decision is the decision on appeal, the appeal period goes all the way back to the Veteran’s original claim for service connection from October 2016. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection for PTSD is granted. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV or DSM-5); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). See 38 C.F.R. § 3.304(f). Factual Background In a March 2017 VA examination report, the examiner found that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD or any other mental disorder under the DSM-5. During the examination, the VA found that the Veteran’s stressor was not adequate to support a diagnosis of PTSD. No causal linkage opinion was given. In an October 2018 Disability Benefits Questionnaire (DBQ), the Veteran was diagnosed with PTSD. The examiner noted that the Veteran reported that his symptoms began shortly after a “frag combat tour” in 2003. No causal linkage opinion was given in this examination. In a November 2018 VA examination report, the Veteran was again found to have no mental disorder diagnosis that conformed to the DSM-5. The examiner opined that the Veteran reported a few mild symptoms which were expected when a person serves in a combat zone. However, these symptoms failed to meet the diagnostic criteria for a mental illness and were at least as likely as not a result of the Veteran’s job working for the police department. The VA examiner never discussed or addressed the October 2018 PTSD diagnosis or whether the Veteran’s symptoms could have been aggravated by his service. At his March 2021 Board hearing, the Veteran testified that, in 2003, shortly before his tour of duty with the Marines ended, he was involved in combat. He reported that, after this experience, he could not sleep when he returned home after service. The Veteran testified that, while he was being processed out of the service, he raised the issue of his sleeping problems but was not provided with an exit examination. The Veteran noted that he was separated from service within two weeks after his combat stressor occurred. The Veteran testified that he sought treatment for his PTSD after he got a job and had health insurance. He reported that he had a mental breakdown a few years later but his doctor (a general practitioner) told him at the time that he was fine. The doctor told the Veteran that he did not believe in mental health problems and that he told the Veteran that he “just needed some rest” and gave him sleeping pills. The Veteran testified that he has nightmares and trouble sleeping, constantly waking up in the middle of the night, and that he has the same 2 or 3 nightmares about “a child’s dead body, red shorts, blue shirt, with a man pointing at him” – the first dead body the Veteran had ever seen. The Veteran stated that he had tremors and has even wet his bed while trying to sleep. He testified that he wakes up shaking and covered in sweat. The Veteran reported that he had suicidal ideas but does not act on them because of his family. He testified that he has some coping mechanisms for his PTSD symptoms but has tried to avoid medication. The Veteran reported that he has had these nightmares ever since service. Sometimes his nightmares ease up but sometimes they get worse and they have been generally getting worse over the years. Analysis The Board finds the March 2017 and November 2018 VA examination reports to be inadequate. Inadequate medical examinations and opinions include examinations that contain only data and conclusions without an explanation tying the two together, do not provide a causal linkage opinion, are not based upon an accurate factual premise, or provide unsupported conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The March 2017 VA examination report contained no nexus opinion. The November 2018 examination report did not address the October 2018 diagnosis of PTSD. Because of this, both VA examination reports have no probative value. Although a causal relationship has not been demonstrated through the foregoing VA opinions, nor otherwise shown through competent medical opinion evidence, the absence of a “valid medical opinion” is not an absolute bar to service connection. Davidson v. Shinseki, 581 F.3d at 1316. The Board finds the reports by the Veteran, including his March 2021 testimony, of experiencing a stressful event in service or fear of hostile military or terrorist activity, to be competent and credible evidence of a valid stressor event for PTSD diagnostic purposes. 38 C.F.R. § 3.304(f). Combined with the October 2018 diagnosis of PTSD, this leads the Board to determine that, at the very least, the evidence is evenly balanced for and against (“in relative equipoise”) as to whether the Veteran’s current PTSD is related to active service. Because of this, it is at least as likely as not that the Veteran’s current PTSD is related to his in-service combat stressor. Accordingly, resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for PTSD is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 125(a). VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Abrams, 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.