Citation Nr: 21026678 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 18-24 707 DATE: May 3, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD) and adjustment disorder with anxiety, to include as due to military sexual trauma (MST), is remanded. REASONS FOR REMAND The Veteran served on active duty for training (ACDUTRA) in the Army from August 1987 to January 1988 and had subsequent service with the Army Reserve and National Guard. This matter is on appeal of an April 2017 rating decision. In February 2021, a hearing was held before the undersigned. A transcript of the hearing is of record. During the hearing, the Veteran stated she is homeless and having financial difficulties and submitted supporting evidence to this effect. Based on that information, the Board herein grants her motion to have the appeal advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c) (2020) for severe financial hardship. The Veteran submitted her claim for PTSD due to MST in September 2016. Although the Agency of Original Jurisdiction (AOJ) addressed her claim as being only for PTSD because the evidence reflects multiple mental health diagnoses during the appeal period, this claim is recharacterized to contemplate all current diagnoses. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Initially, the Board notes that the AOJ denied the Veteran's claim in part because it was determined she was not on active duty, active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA) at the time she was sexually assaulted. During her February 2021 hearing, the Veteran testified that her Army Reserve unit was called up early in August 1990 and deployed to Ft. Stewart to train for a few months prior to being deployed to Saudi Arabia. Prior to her deployment to Ft. Stewart, she reported to her unit in Tallahassee, Florida on a daily basis. She testified that after she was assaulted, she notified her commanders and asked for dental care because her assailant had hit her in the jaw and she also requested counseling. She testified that her requests were ignored, and she was accused of just trying to get out of her deployment and threatened with being court marshalled. The Veteran further testified that she did stay with her unit, training at Ft. Stewart for approximately 6 months before a commanding officer found her to be non-deployable. Orders dated July 5, 1990, show that the Veteran was reassigned to the 400th MP headquarters for annual training duty effective July 3, 1990. In February 2021 shortly after her hearing was conducted, the Veteran also submitted copies of pay records for August 1990 that show she was being paid for "UT" or unit training for which she was assigned July 3, 1990. An August 26, 1990 police report from the Tallahassee Police department indicates the Veteran was sexually assaulted that date. Her service treatment records show that she was later treated for pelvic inflammatory disease in January 1991, at a medical facility at Ft. Stewart. Orders dated February 6, 1991, show the Veteran was reassigned to another unit for transition processing. The orders indicate that after processing she would be released from active duty effective February 8, 1991. They also state that she was non-deployable at that time with a recommendation that a medical evaluation or action be taken. The Board finds that the balance of the evidence reflects that the Veteran was serving on at least a period of INACDUTRA at the time of the sexual assault in August 1990 and resolves doubt in her favor on this aspect of her claim. The AOJ further denied the Veteran's claim in part because she did not have a current PTSD diagnosis and that her diagnosed psychiatric disorders were not etiologically linked to her service or any incident therein. The decision is partially predicated on a March 2017 VA examiner's opinion that the Veteran's symptoms did not meet the diagnostic criteria for a PTSD diagnosis and that her diagnosed adjustment disorder with anxiety was less likely as not a result of an in-service stressor related event. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. A medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history, even if recorded in the course of the examination. Dalton v. Nicholson, 21 Vet. App. 23 (2007); see Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The March 2017 VA examiner's opinion does not provide supporting rationale for her opinion that the Veteran's diagnosed adjustment disorder with anxiety was less likely related to any incident in service. However, it does appear that the opinion was based to some degree on the lack of contemporary medical treatment records as the examiner notes that the Veteran has not required mental health treatment since 2007, despite such treatment being available to her at any time. Additionally, the opinion did not address the Veteran's other psychiatric diagnoses of GAD and MDD. For these reasons, the Board finds the March 2017 VA opinion inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (noting that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). An additional examination with opinion should be obtained on remand. The matter is REMANDED for the following action: 1. Obtain any updated VA treatment records from January 2017 to the present. 2. After associating the above records, schedule the Veteran for a VA examination (including via telehealth) to assess the nature and etiology of her psychiatric disorder. The electronic claims file must be made available to the examiner. The examiner should answer the following questions: (a). Does the Veteran have a diagnosis of PTSD under DSM-5 criteria? (b). If the answer to (a) is yes, then is it at least as likely as not (50 percent or better probability) that such psychiatric disorder began in service or is otherwise related to the Veteran's documented sexual assault in August 1990? (c). For any currently or previously diagnosed psychiatric disorder other than PTSD, to include MDD, GAD and adjustment disorder with anxiety, is it at least as likely as not (50 percent or better probability) that it is related to the Veteran's documented sexual assault in August 1990? In providing these opinions, the clinician is advised that the Board has made a finding that the Veteran's August 1990 sexual assault occurred during a period of INACDUTRA. Thus, the opinion should not be based on a conclusion that the Veteran's stressor did not occur in service. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. J. Wells-Green 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.