Citation Nr: 21030216
Decision Date: 05/18/21	Archive Date: 05/18/21

DOCKET NO. 17-02 292
DATE: May 18, 2021

REMANDED

Entitlement to an initial compensable rating for traumatic brain injury (TBI) with headaches and dizziness is remanded.

Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the U.S. Navy from August 2003 to August 2008.  These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by a Regional Office (RO) of the United States Department of Veterans Affairs (VA).

The Veteran testified at a March 18, 2020 hearing held before the undersigned.  In January 2021, VA informed the Veteran that it was unable to produce a complete transcript of the proceeding due to audio malfunctions in its Digital Audio Recording System (DARS).  The Veteran was further advised of the opportunity to testify at another hearing under 38 C.F.R. § 20.717.  No response was received from the Veteran within 30 days of the letter.  Therefore, the Board will proceed with its decision on the merits.

Further development is required in connection with the increased rating claims for service-connected TBI with headaches and dizziness and service-connected PTSD.

Reports from the Veteran indicate that the symptoms associated with his TBI and PTSD have worsened.  At the March 2020 Board hearing, the Veteran endorsed suicidal ideations, flattened affect, impulsive behavior, verbal aggression, belligerence, problems with supervision, lack of empathy, irritability, memory loss, and migraine headaches two to three times per week.  The Veteran was last afforded VA examinations for respective disabilities in December 2014.  Notwithstanding, the most recent VA treatment records are through August 2016, and the most recent private treatment records are through February 2017.  In light of the reports of the Veteran's worsening state since the most recent examination, the Board finds that new VA examinations are needed to assess the current severity of the Veteran's TBI and PTSD in order for the Board to make a fully informed decision.  

Updated private and VA treatment records should be requested on remand.  38 U.S.C. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if the material could be determinative of the claim).

The matters are REMANDED for the following action:

1. Contact the Veteran and request properly executed, separate VA Form 21-4142's, Authorization and Consent to Release Information to the Department of Veterans Affairs, for any private care providers who have treated him for his TBI and PTSD.

Upon receipt of such, VA must take appropriate action to contact the identified providers and request complete treatment records.  The Veteran should be informed that in the alternative he may obtain and submit the records himself.

2. Schedule the Veteran for a VA examination to ascertain the current nature and severity of his service-connected TBI with headaches and dizziness.

Any appropriate evaluations, studies and testing deemed necessary by the examiner should be conducted and their results included in the examination report.  

3. Schedule the Veteran for a VA examination to ascertain the current nature and severity of his service-connected PTSD.

 

 

TRACIE N. WESNER

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	G.A. Ong, 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.