Citation Nr: 21025940 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-23 555 DATE: April 29, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for residuals of a laceration of left ankle is remanded. Entitlement to service connection for neuropathy of the bilateral lower extremities is remanded. Entitlement to service connection for a back disability is remanded. FINDING OF FACT The Veteran’s PTSD is etiologically related to his active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. § 1110 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Army from August 1970 to February 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2012 and August 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). A November 2018 Board decision denied the Veteran’s claim of reopening the previous denial of service connection for residuals a back disability and denied service connection for an acquired psychiatric disorder. A February 2020 Memorandum Decision of the Court of Appeals for Veterans Claims (Court) reversed that portion of the Board decision that denied reopening the previously denied claim of service connection for residuals of a back injury and remanded the matter to the Board. The Court also vacated that part of the decision that denied service connection for an acquired psychiatric disorder and remanded that matter to the Board. In January 2021, the Board reopened the claim for service connection for a back disability and remanded the underlying claim for service connection as well as the service connection claims for residuals of a laceration of left ankle, neuropathy of the bilateral lower extremities, and an acquired psychiatric disorder. The claims were remanded, in pertinent part, to obtain VA examinations and etiology opinions for the issues on appeal. Service Connection – Psychiatric Disorder As an initial matter, it appears that the appeal has been returned to the Board prematurely. Specifically, there is no supplemental statement of the case (SSOC) reflecting consideration of a VA psychiatric examination conducted in February 2021. However, given that the Board is granting this claim in full, remand for issuance of a SSOC is not warranted as there is no prejudice to the Veteran and failure to issue a SSOC is harmless error with regard to the claim for a psychiatric disorder. The Veteran has contended that his psychiatric disability, claimed as PTSD, is related to his active service. Specifically, he reported that he was exposed to life-threatening situations when he served on perimeter duty while serving in the Republic of Vietnam. He indicated that he had to return gunfire and was exposed to incoming gunfire during that time. The Veteran’s stressors are consistent with his service in the Republic of Vietnam. A review of the Veteran’s DD Form 214 reflects service in the Republic of Vietnam from January 1971 to December 1971. The Veteran was afforded a VA examination in June 2015. Upon examination, the examiner stated that based on the clinical interview, analyses of symptoms endorsed, reported events/stressors, Vietnam-disclosed exposure, and claims file review, the Veteran does not meet the criteria for a diagnosis of PTSD nor does the Veteran meet any DSM-5 (Diagnostic and Statistical Mental Disorders, Fifth Edition) diagnosis that significantly interferes with his daily functioning or that is at least as likely as not related to his military service. However, the Court determined that the examination was inadequate. The Veteran was afforded another VA examination in February 2021, at which time he was diagnosed with PTSD based on his reported in-service stressors and psychiatric testing. The examiner opined that PTSD was at least as likely as not incurred in or caused by service. The examiner’s rationale was that the Veteran identified multiple stressors during his service in Vietnam which met Criterion A for a diagnosis of PTSD pursuant to DSM-IV (Diagnostic and Statistical Mental Disorders, Fourth Edition) and DSM-V. The examiner noted that the Veteran has an acquired psychiatric disorder identified as PTSD which is related to his period of service in Vietnam. The examiner stated that the Veteran’s military stressors led to substance abuse following service (in full remission) and his current symptoms are consistent with a diagnosis of PTSD. The examiner, a VA psychologist, relied on his own training, knowledge, and expertise in rendering his opinion. For this reason, the opinion is considered highly probative and given considerable weight. Moreover, the Board notes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran is competent to identify symptoms related to a psychiatric disability, and report on the chronicity of symptomatology since active service. Moreover, his statements have been found credible. In sum, the Board has conceded the Veteran’s in-service stressors. The Veteran has competently and credibly reported that that he first experienced symptoms associated with a psychiatric disability while in active service and that he has continued to experience symptoms since that time, and those statements have been found credible by the Board. Furthermore, the Veteran has current diagnosis of a psychiatric disability that a VA psychologist has determined is related to his active service. Accordingly, the Board finds that entitlement to service connection for a psychiatric disability is warranted. REASONS FOR REMAND As noted, it appears that the appeal was returned to the Board prematurely. Specifically, there is no SSOC reflecting consideration of VA examinations conducted in February and March 2021 with regard to the remaining claims on appeal. Therefore, the Board is returning the matter to the RO so that development can be completed, and a SSOC issued for the claims of entitlement to service connection for residuals of a laceration of left ankle, neuropathy of the bilateral lower extremities, and a back disability. 38 C.F.R. § 19.31. The matters are REMANDED for the following action: After completing any other development as may be indicated, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran should be issued a SSOC. Roya Bahrami Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Cryan, 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.