Citation Nr: 21026432 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 14-07 006A DATE: May 3, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for frostbite of the bilateral hands is remanded. Entitlement to service connection for frostbite of the bilateral feet is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1976 to November 1979. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in February 2018. A transcript of the hearing has been associated with the record. 1. Entitlement to service connection for a low back disability is remanded. 2. Entitlement to service connection for frostbite of the bilateral hands is remanded. 3. Entitlement to service connection for frostbite of the bilateral feet is remanded. The Veteran contends that each of the above-captioned conditions were incurred in or are related to active service. When these matters were last before the Board in July 2018, they were remanded to obtain any service treatment records (STRs) that had not been associated with the claims file and to afford the Veteran VA examinations. The Board finds that additional remand of the claims is necessary. The Veteran was afforded VA examinations for each of the claimed conditions in May 2019. In finding that none of the conditions were related to active service, the examiner stated only that there was no evidence of the Veteran being treated in service for his claimed conditions. Here, the Board notes that opinions based on absence of treatment records without consideration of the Veteran's reports is inadequate. See Dalton v. Nicholson, 21 Vet. App. 12 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Thus, as the opinion rendered is based wholly on the absence of treatment records, the Board finds that the opinions are incomplete for adjudicative purposes. For this reason, remand is warranted to obtain addendum medical opinions as to the etiology of the Veteran's low back disability, bilateral hand, and bilateral foot conditions. Additionally, it is clear that portions of the Veteran's STRs have not been associated with the claims file. Notably, the only medical record available in the Veteran's STRs is his entrance examination. An April 2019 correspondence indicates that all efforts to obtain the Veteran's STRs have been exhausted, and that further attempts to obtain the records would be futile. Because the full service treatment records are unavailable, the Board has a heightened obligation to explain its findings and to consider the benefit-of-the-doubt rule set forth in 38 C.F.R. § 3.102. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Accordingly, for the purpose of rendering the requested opinion, the examiner should accept as true the Veteran's accounts of falling from a ladder and injuring his back during service in Korea, and sustaining frostbite of his hands and feet during basic training. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion to determine the nature and etiology of the Veteran's claimed low back disability. The necessity for a reexamination of the Veteran is left to the designated VA examiner's discretion. After reviewing the claims file, the examiner is asked to provide the following opinions: a.) Identify all current back disabilities present since the claim (i.e. since November 2011). b.) For each diagnosis, the examiner should offer an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disability had its onset in or is otherwise related to his service. For the purposes of rendering an opinion, the examiner must accept as true the Veteran's reports of falling from a ladder, injuring his back, and being treated at the base hospital, Yongsan, in Seoul, Korea for four days. Opinions based on absence of treatment records without consideration of the Veteran's reports is inadequate. See Dalton v. Nicholson, 21 Vet. App. 12 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). 2. Obtain an addendum medical opinion to determine the nature and etiology of the Veteran's claimed residuals of frost bite of the bilateral hands and feet. The necessity for a reexamination of the Veteran is left to the designated VA examiner's discretion. After reviewing the claims file, the examiner is asked to provide the following opinions: a.) Identify all current bilateral hand and foot disabilities present since the claim (i.e. since November 2011). b.) For each diagnosis, the examiner should offer an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disability had its onset in or is otherwise related to his service. The examiner must accept as true the Veteran's reports of sustaining frostbite of his hands and feet during Basic training at Fort Dix, New Jersey, and being hospitalized for two days for the injuries. Opinions based on absence of treatment records without consideration of the Veteran's reports is inadequate. See Dalton v. Nicholson, 21 Vet. App. 12 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Marsh II, 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.