Citation Nr: 21032377 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 14-02 438 DATE: May 26, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, major depressive disorder, unspecified anxiety disorder, and insomnia disorder is remanded. REASONS FOR REMAND The Veteran had active service with the US Marine Corps from June 1973 to June 1977 and December 1977 to December 1979. This matter is on appeal to the Board of Veterans' Appeals (the Board) from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Board denied entitlement to service connection for an acquired psychiatric disorder, to include PTSD, adjustment disorder with depressed mood, depressive disorder, and anxiety. The Veteran subsequently appealed to the United States Court of Appeals for Veterans Claims (the Court). In a November 2020 order, the Court granted the parties' Joint Motion for Remand (JMR), vacating the Board's July 2019 denial of service connection for an acquired psychiatric disorder, and remanded to the Board for readjudication consistent with the JMR. The Court found the statement of reasons and bases in the July 2019 Board denial to be inadequate. The Court indicated the Board denial failed to address all the psychiatric diagnoses listed in his VA treatment records. Mental health treatment records from November 2018 show the Veteran was diagnosed with insomnia disorder, unspecified anxiety disorder, and major depressive disorder, single episode, unspecified. Therefore, the Court found remand was warranted to address these conditions. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Court also found the VA's duty to assist was not satisfied. A May 1978 service treatment note indicated the Veteran was referred to the psychology clinic to see Lieutenant Commander (LCDR) Foxx. The Veteran testified at his February 2017 hearing to receiving treatment in service from LCDR Foxx, a psychiatrist. However, there are no service records showing treatment from LCDR Foxx. Additionally, a September 2012 VA mental health outpatient note indicated the Veteran was referred by the Vet Center for evaluation of anger problems and possible PTSD. However, there are no records from the Vet Center associated with the claims file. On remand, the RO should attempt to obtain and associate these records with the claims file. After the above development, the Board finds an addendum opinion from the December 2017 VA examiner should be requested regarding the Veteran's service connection claim for an acquired psychiatric disorder, to include PTSD, adjustment disorder with depressed mood, major depressive disorder, unspecified anxiety disorder, and insomnia disorder. The matters are REMANDED for the following action: 1. Take appropriate steps to obtain any outstanding private or VA treatment records, to include Vet Center treatment records. 2. The RO should contact all relevant record repositories to attempt to obtain any outstanding service treatment records, to include any psychological evaluations conducted following the 1978 referral. If any requested records are not available or the search for any such records otherwise yields negative results, that fact must be clearly documented in the claims file. Efforts to obtain these records must continue until it is determined they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be documented in the record and required notices must be provided to the Veteran. 3. After the above development is complete obtain an addendum opinion from the December 2017 VA examiner regarding the Veteran's service connection claim for an acquired psychiatric disorder, to include PTSD, adjustment disorder with depressed mood, major depressive disorder, unspecified anxiety disorder, and insomnia disorder. If the December 2017 VA examiner is not available, the requested opinion with rationale should be rendered by another qualified clinician. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. (a.) The examiner is asked to opine on the following: If it is at least as likely as not that his acquired psychiatric disorder, to include PTSD, adjustment disorder with depressed mood, major depressive disorder, unspecified anxiety disorder, and insomnia disorder had its onset in service or was otherwise etiologically related to any event or circumstance of his service. The complete record, to include a copy of this remand and the claims folder, must be made available to and reviewed by the examiner in conjunction with the examination. The examination report must include a notation that this record review took place. 4. After completion of the above and any additional development deemed necessary, the issue on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for further consideration. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Byers 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.