Citation Nr: 21025741 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-20 305 DATE: April 28, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability to include posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a left groin condition is remanded. Entitlement to service connection for pericarditis is remanded. Entitlement to service connection for diabetes to include under 38 U.S.C. § 1151 and/or secondary to an acquired psychiatric disability is remanded. FINDING OF FACT The Veteran’s PTSD is related to his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. § 1101, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has confirmed active duty in the United States Army from May 1983 to October 1983 with Army National Guard service from September 1986 to January 1989. The Board notes that the Veteran was provided a hearing on December 2019; unfortunately, there was a malfunction in the audio recording equipment and no transcript could be produced. The Veteran was notified of this deficiency and offered another opportunity to testify in an October 2020 correspondence from the Board. He was provided 30 days to respond otherwise the Board would assume he did not wish to have a new hearing. The 30 days has expired without a response, and the Board has proceeded accordingly. 1. Entitlement to service connection for an acquired psychiatric disability to include posttraumatic stress disorder (PTSD) There is no dispute as to Veteran’s current diagnosis of PTSD or that the Veteran’s PTSD has been related to his reported stressor event in service as documented in a July 2016 VA psychologist opinion. The only question left to determine is the validity of the Veteran’s stressor. The Veteran has identified a stressor event occurring in 1983. The Board notes while the AOJ did not include this period of the Veteran’s service in detailing his active duty service, the Board notes that his period of service is the only confirmed active duty service (i.e. DD-214 documented). The AOJ has not been able to confirm the event. The Board notes that the Veteran’s statements regarding the stressor event have been consistent, and are consistent with the circumstances, types, and places of his service. 38 U.S.C. § 1154(a). Further, he has provided testimony detailing the event that the Board has found credible, and the Board finds that the Veteran is competent to report what he witnessed. Accordingly, the Board finds that the Veteran’s stressor event is corroborated and verified. Given the evidence of record and the Board’s finding regarding the Veteran’s stressor, the Board finds that all elements of service connection for PTSD are met and the claim is granted. See 38 C.F.R. §§ 3.303, 3.304. REASONS FOR REMAND 1. Entitlement to service connection for a left groin condition and pericarditis are remanded. Regrettably, upon review of the evidence, the Board finds that a remand is needed to fulfill the VA duty to assist. Namely, the Veteran should be provided a VA examination to address the Veteran’s contentions, obtain and associate outstanding VA treatment record, and attempt obtain service treatment records from the appropriate custodians to include the Veteran’s National Guard unit. The Veteran contends that he suffered from a left groin condition and pericarditis in service and continues to suffer from these conditions today. The Board notes that the Veteran’s contention have not been examined by a competent medical authority (i.e. a VA examination have not been provided.) Upon review of the claims file, the Board finds that a VA examination should be provided to the Veteran. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Moreover, the Board finds that the claims file only contains VA treatment records up until October 2016 while there is evidence that the Veteran continues has continued to seek VA medical treatment. These records should be obtained and associated with the claims file. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Last, the Board notes that while the Agency of Original Jurisdiction (AOJ) has determined that the Veteran’s service treatment records are unavailable in a September 2013 Memorandum of Unavailability there is no evidence that VA has contacted the Veteran’s National Guard unit where he completed his last period of service. Similarly, the Board notes that the only DD-214 in the Veteran’s claims file documents service from May 1983 to October 1983. While the AOJ wrote in previous rating decisions that the Veteran’s active duty service in the Army was from September 1986 to January 1989, the claims file contains evidence that this period of service may not have entirely been active duty. Namely, a September 26, 1985 Order which activated the Veteran for the Army National Guard for “full time training duty” and January 1987 testimony, unrelated to present claim, wherein the Veteran testified that he worked full-time for the Active Guard Reserve (AGR). The Board finds that additional efforts should be made to clarify the Veteran’s service and obtain his service treatment records to include contacting his Army National Guard unit the “A Battery 2 -122 FA, S. 200 S. Cottage Grove, Chicago, Illinois.” See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 2. Entitlement to service connection for diabetes to include under 38 U.S.C. § 1151 and/or secondary to an acquired psychiatric disability is remanded. The Veteran contends that his diabetes is related to his now service connected acquired psychiatric disability or alternatively the results of carelessness on the part of VA for prescribing medication which later caused his diabetes. Upon review, the Board finds that a VA examination should be provided to the Veteran to further investigate his contentions. There is no dispute that the Veteran has been diagnosed of diabetes as noted in an August 2016 VA treatment note. Likewise, the Veteran has been service connected for an acquired psychiatric disability. The only dispute is whether the Veteran’s service connected disability or alternatively, the Veteran’s VA care resulted in the development of diabetes. The VA claims file contains only the Veteran’s contention which are in themselves insufficient for the Board to make a determination on what is inherently a medical analysis. As such, the Board finds that that the Veteran should be provided a VA examination to address his contentions. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As a VA examination is being provided the Board finds that for the sake of judicial prudence, the examiner should also address the Veteran's claim for compensation under 38 U.S.C. § 1151, in which he contends that his diabetes was caused by medication provided to him by VA. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his disabilities. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. Regardless of the Veteran’s response, VA treatment records should be updated from October 2016 from the Jesse Brown VA Medical Center, Chicago, Illinois and associated clinics and outpatient facilities. Any archived records should be retrieved from storage. 2. The AOJ should ensure that all service treatment records and service hospital records from all periods of verified active duty service have been associated with the claims file. In particular, the Board is interested in medical records from his time with the Illinois National Guard: A Battery 2 -122 FA, S. 200 S. Cottage Grove, Chicago, Illinois which may be located at the Illinois National Guard. To this end, the AOJ should contact the Illinois Army National Guard at 1301 N. MacArthur Blvd, Springfield, IL 62702. 3. After the above development is accomplished, schedule the Veteran for appropriate VA examinations. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiners as part of the examination. A notation to the effect that this review has taken place should be made in the evaluation report. All tests, studies, and evaluations should be performed as deemed necessary by the examiners, and the results of any testing must be included in the examination report. (A) LEFT GROIN: After considering the pertinent information in the record in its entirety, the VA examiner should identify any left groin condition present. The examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that any left groin condition identified was incurred or aggravated by his active duty or otherwise etiologically related to his active duty service, and if not, why. In providing an opinion the VA examiner should take a detailed history from the Veteran regarding the onset of this disability and any continuity of symptoms since that time. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (B) PERICARDITIS: After considering the pertinent information in the record in its entirety, the VA examiner should identify any pericarditis condition present. The examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that any pericarditis condition identified was incurred or aggravated by his active duty or otherwise etiologically related to his active duty service, and if not, why. In providing an opinion the VA examiner should take a detailed history from the Veteran regarding the onset of this disability and any continuity of symptoms since that time. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (C) DIABETES: After taking a detailed history from the Veteran regarding his diabetes and considering the pertinent information in the record in its entirety, the VA examiner should opine whether it is at least as likely as not, i.e. 50 percent probability or greater, that the Veteran's diabetes was caused or aggravated by the Veteran’s service connected acquired psychiatric disability or is otherwise etiologically related to the Veteran’s active service, and if not, why. (D) 38 U.S.C. § 1151 CLAIM FOR DIABETES: After taking a detailed history from the Veteran regarding his diabetes and considering the pertinent information in the record in its entirety: (i) the VA examiner should opine whether it is as least as likely as not (50 percent probability or more) that the Veteran prescription use of Seroquel while in VA care for his acquired psychiatric disability, caused the additional disability of diabetes. (ii) If the above in answered in the affirmative, the VA examiner should opine as to whether it is as least as likely as not (50 percent probability or more) any such additional disability was proximately caused by or the result of any carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing treatment or whether any such additional disability proximately was due to an event that was not reasonably foreseeable. 4. Ensure that the examination report complies with this remand and the questions presented in this request. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 5. After completing the requested actions and any additional notification and/or development deemed warranted, readjudicate the issues on appeal. GAYLE E. STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Acosta, 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.