Citation Nr: 21025636 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-58 242 DATE: April 28, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD), depression, and anxiety is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1955 to November 1977. The matter was previously before the Board in June 2017 and March 2020. Most recently the claim was remanded for an adequate opinion addressing secondary service connection and the Veteran’s lay statements as to the onset of symptoms related to his psychiatric disorder. An addendum opinion was associated with the file in January 2021. The claim has been returned to the Board for appellate review. 1. Entitlement to service connection for an acquired psychiatric disorder, claimed as PTSD, depression, and anxiety is remanded. The Veteran contends that he began experiencing psychiatric symptoms during his active duty service. Specifically, the Veteran reported that after his hospitalization for stomach issues, he became increasingly aggressive and started fighting with his comrades leading to disciplinary action. The Veteran’s post-service treatment records show psychiatric treatment dating back at least thirty years. Pursuant to the Board’s March 2020 remand, the Veteran was provided a new VA examination in January 2021 to determine the nature of the Veteran’s psychiatric conditions and their relationship to his active duty service. The Veteran was diagnosed with insomnia. The examiner opined that it was less likely than not that the Veteran’s diagnosed insomnia was related to his service. However, the Board finds the VA opinion inadequate. Without providing any medical basis to doubt the Veteran’s statements, the examiner relied solely on the lack of documentation to support the opinion. Additionally, the March 2020 remand directed the examiner to opine as to secondary service connection. The examiner found “no evidence of a mental disorder being proximately due to or the result of the Veteran’s service-connected peptic ulcer disease, chronic gastritis, gastroesophageal reflux disease and hernia hiatal.” The Board notes that secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310 (2016). Therefore, the question of “aggravation” is pertinent in order for the Board to properly adjudicate the Veteran’s claim. Accordingly, further remand is necessary to ensure compliance with the March 2020 remand directives. A VA examiner should provide an addendum opinion that adequately addresses the lay evidence of record and all theories of entitlement. 2. Entitlement to a TDIU is remanded. Finally, because a decision on the issue of service connection for a psychiatric disorder could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. A remand for the claim for TDIU is required. The matters are REMANDED for the following action: 1. The AOJ should forward the entire claims file in electronic records to the January 2021 VA examiner, if that examiner is unavailable, then to a suitably qualified VA examiner. The examiner should review the claims folder and acknowledge such review. If additional examination is indicated, it should be scheduled in accordance with applicable procedures and all indicated studies should be performed. 2. The examiner should provide an opinion regarding the nature and etiology of the claimed disabilities, which addresses the Veteran’s service treatment records, post-service medical records, and lay statements. The examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s acquired psychiatric disorder had its onset in service or is otherwise related to his active duty service. The examiner should also provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s acquired psychiatric disorder is aggravated by the Veteran’s peptic ulcer disease, chronic gastritis, gastroesophageal reflux disease and hernia hiatal and any associated treatment. All opinions must be accompanied by a clear rationale. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. After ensuring compliance with these objectives, the AOJ should readjudicate the remanded claims, to include the claim for a TDIU. If either benefit sought on appeal is not granted, the Veteran should be provided a supplemental statement of the case and an appropriate time period for response. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Sherman Associate 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.