Citation Nr: 21025969 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-30 417 DATE: April 29, 2021 REMANDED Entitlement to service connection for an unspecified psychotic disorder, claimed as anxiety depression disorder (psychiatric disability), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1971 to August 1971. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In his June 2016 substantive appeal, the Veteran requested the opportunity to testify at a hearing held before a Veterans Law Judge. This hearing was scheduled in January 2020, but the Veteran did not appear. The Veteran has not requested that the hearing be rescheduled. Therefore, the request for a Board hearing is deemed withdrawn. 38 C.F.R. § 20.704(d). Entitlement to service connection for an unspecified psychotic disorder, claimed as anxiety depression disorder (psychiatric disability), is remanded. The Veteran is seeking service connection for a psychiatric disorder that he asserts is related to his in-service experiences. Although the Board regrets the delay, additional development is required before it can adjudicate the Veteran’s claim. Review of the Veteran’s service treatment records show that in July 1971, he was evaluated as an outpatient at the health clinic on base, after three weeks on active duty. See HQ 3rd BDE Clinic Notes, Narrative Summary, dated July 23, 1971. The Veteran was diagnosed with mixed anxiety and hysterical neurosis. Id. The summary reported there was a “history of severe emotional difficulties since age 5 requiring intermittent psychotherapy and psychiatric hospitalization at Mercy Clinic in Sacramento, California.” Id. The Veteran’s June 1971 induction medical examination is negative for a history or a diagnosis of a psychiatric disability. In such circumstances, a Veteran is presumed to have been sound upon entry, and the burden falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Veteran was afforded a VA examination in connection with this claim in June 2014. Unfortunately, the examination request was written in terms of aggravation of a condition noted on entrance, and, as a result, the examiner who conducted the examination did not issue an opinion that fully addressed the appropriate standard. Thus, an additional medical opinion that addresses whether the Veteran’s diagnosed mental health disorder both clearly and unmistakably preexisted service and was clearly and unmistakably not aggravated by service is needed on remand. Additionally, in January 2020, the Veteran submitted a letter from a private clinician who reported that the Veteran was receiving psychiatric treatment at a behavioral health facility. As these records may be relevant to the Veteran’s appeal, he should be given the opportunity to either submit them or authorize VA to obtain them. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for KBBH, so that the records associated with his treatment for a psychiatric disorder at that facility may be obtained. If the form is received, make two requests for the records, unless it is clear after the first request that a second request would be futile. Any negative responses should be in writing and should be associated with the claims file. 2. After completing the development in paragraph 1 to the extent possible, send the claims file to an appropriate clinician for review. If a new examination is deemed necessary to respond to the questions posed, one should be scheduled. Following review of the claims file, the clinician is asked to respond to the following: (a) Please identify all current mental health disorders. In doing so, please specifically discuss the psychiatric diagnoses of record, including but not limited to unspecified psychotic disorder and posttraumatic stress disorder. For any diagnoses of record that cannot be validated or confirmed, please explain why that is so. (b) For each mental health disorder identified, did the disorder clearly and unmistakably (i.e., obviously, manifestly, or undebatably) preexist the Veteran’s period of active service? Please explain why or why not. (c) If you determine that any mental disorder clearly and unmistakably preexisted service, does the evidence clearly and unmistakably (i.e., obviously, manifestly, or undebatably) show that the preexisting condition did not undergo an increase in the underlying pathology, i.e., an aggravation, during service, or that any increase in disability was due to the natural progression of the disease? Please explain why or why not. (d) For any diagnosed mental health disorder that did not clearly and unmistakably preexist service, is it at least as likely as not (50 percent probability or more) that the disorder had its onset in, or is otherwise related to, the Veteran’s active service? Please explain why or why not. L. STEPANICK Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Davidson 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.