Citation Nr: 21028109 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 10-41 611 DATE: May 10, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected schizophrenia is remanded. REASONS FOR REMAND The Veteran served honorably on active duty for training in the U.S. Army National Guard of Pennsylvania from October 1979 to January 1980, with additional inactive service in the Army National Guard and Army Reserve. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board denied service connection for hypertension in December 2017. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion for Remand filed by the parties, the Court remanded the matter to the Board in August 2018 for action consistent with the terms of the Joint Motion. In turn, the Board remanded the matter in March 2019 and September 2020 for additional development and the matter has been returned to the Board. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected schizophrenia is remanded. The Board regrets the delay, but additional development is necessary to satisfy VA's duty to assist. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records, VA medical records, records from facilities with which the VA has contracted, and records from Federal agencies such as the Social Security Administration. 38 C.F.R. § 3.159(c)(2). VA will end its efforts to obtain records only where it concludes that the records sought do not exist or that further efforts to obtain those records would be futile, such as where the Federal department or agency advises VA that the requested records do not exist or the custodian does not have them. 38 C.F.R. § 3.159(c)(2). In this case, the record indicates there are outstanding VA treatment records. The September 2020 Board remand directed VA to obtain federal records from the Social Security Administration (SSA) relevant to the Veteran's SSA disability claim, which were then associated with the claims file in March 2021. On his SSA application forms, the Veteran reported receiving regular medical care at the VA Medical Center in Philadelphia since the 1970s. Currently, the only VA treatment records in the claims file are from 2015 through 2021. Thus, remand is required to obtain any outstanding VA treatment records from the 1970s through 2015. If any additional records are received, VA must obtain an addendum opinion addressing whether hypertension had onset during the Veteran's period of service or within one year of separation. Most recently, a March 2021 VA examiner opined that hypertension did not have onset in service or within one year of separation from service. In support of that opinion, the examiner reported that the available medical records did not show hypertension until 2008. If new records are received, the claims file should be returned to a VA examiner for review and an addendum opinion. The matters are REMANDED for the following action: 1. Obtain all VA treatment records from the VA Medical Centers in Philadelphia and/or Lebanon from the 1970s through 2015; and from 2021 onward. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. IF new records are received as a result of this remand, return the claims file to a qualified medical examiner for an addendum opinion on the etiology of the claimed hypertension. (a.) The examiner must opine whether the Veteran's hypertension at least as likely as not (a 50 percent or greater probability) (1) began during active service; (2) manifested within one year after discharge from service; or (3) was noted during service with continuity of the same symptomatology since service, to include a September 2018 VA treatment record noting the Veteran's life-long hypertension. (b.) The examiner is advised that the lack of documentation of hypertension in service treatment records is not, by itself, a sufficient rationale for a negative opinion. 3. Then, the record should again be reviewed. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond. Robert N. Scarduzio Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Smith, 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.