Citation Nr: 21027911
Decision Date: 05/07/21	Archive Date: 05/07/21

DOCKET NO. 20-07 912
DATE: May 7, 2021

REMANDED

Entitlement to a disability rating in excess of 30 percent for left eye blindness is remanded.

Entitlement to a compensable disability rating for traumatic brain injury (TBI) is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Army from June 1970 to May 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a virtual Board hearing before the undersigned.

The Board recognizes that a separate appeal from the Veteran is active before the Board. However, that appeal is docketed in the Board's modernized review system, also known as the Appeals Modernization Act (AMA), and therefore, will be adjudicated in a separate AMA decision.

1. Entitlement to a disability rating in excess of 30 percent for left eye blindness is remanded.

2. Entitlement to a compensable disability rating for TBI is remanded.

During his March 2021 Board hearing, the Veteran asserted that his TBI and left eye disability have worsened since his last VA examinations in April 2017 and May 2017, respectively. Specifically, he indicated that he experiences an increase in blurry vision and received new glasses in 2020 for deteriorating vision. He also testified that his TBI has caused increased symptoms as to difficulty with concentration and uncontrollable body shakes. Therefore, new VA examinations are needed to ensure that the record reflects the current severity of the Veteran's left eye disability and TBI. The duty to conduct a contemporaneous examination is triggered when the evidence indicates that there has been a material change in disability or that the currently assigned disability rating may be incorrect. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997).

During the Veteran's March 2021 Board hearing, he indicated that he continues to receive treatment for his left eye disability at the Dorn VA Medical Center, to include a recent VA ophthalmology visit in late 2020. Review of the Veteran's claims file reflects VA treatment records up to January 2020. VA has a duty to seek those outstanding VA treatment records identified by the Veteran during his March 2021 Board hearing, as they pertain to the current severity of the Veteran's left eye disability. 38 U.S.C. § 5103A(b)(1).

The matters are REMANDED for the following action:

1. With any necessary identification of sources and authorization by the Veteran, request all VA and private treatment records for the Veteran not already associated with the file, to specifically include VA treatment records from the Dorn VA Medical Center from January 2020 to the present. Copies of any outstanding VA and private treatment records should be added to the Veteran's electronic claims file.

2. Thereafter, schedule the Veteran for VA examinations by examiners with appropriate expertise to determine the nature and current severity of his service-connected left eye disability and service-connected TBI. The Veteran's electronic claims file must be accessible for review by the VA examiners in conjunction with the examinations. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiners should be performed and the results reported in detail. Detailed rationales for all opinions expressed should be provided.

 

J. B. FREEMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Houle, 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.