Citation Nr: 21032534 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-19 056 DATE: May 27, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) to include as due to military sexual trauma (MST), is remanded. REASONS FOR REMAND The Veteran served on active duty with the Army from August 1968 to September 1971 to include service in the Republic of Vietnam and Laos. The Veteran died in in April 2018. The appellant is his surviving spouse and was recognized as his substitute in June 2018. This appeal to the Board of Veterans' Appeals (Board) arose from an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Board remanded the instant matter for additional development. Entitlement to service connection for PTSD is remanded. The appellant contends that the Veteran's acquired psychiatric disorder is due to in-service events to include a possible military sexual trauma (MST) he experienced while on active duty. Specifically, in an August 2012 correspondence, the Veteran identified two specific events: he first recalls an event sometime in late July or early August related to rocket attack, wherein the Veteran reported to a guerilla attack in Laos while he was away and never seeing the sergeant again after the rocket attack. The second event the Veteran recounted has to do with the claimed sexual assault. The Veteran reported becoming intoxicated and waking up next morning to find his clothes being rearranged and the belt on backwards. Approximately three to four days after the event, he reported to the doctor for an unrelated physical matter who diagnosed him with thrombosed hemorrhoid. The doctor explained to the Veteran that the hemorrhoid was often indicator of something being "forced in or forced out." The Veteran's military personnel record shows a demotion in August 1971 but an honorable discharge in September 1971. Reasons for the demotion is not specifically provided. The September 2013 VA examiner reviewed the medical records, examined the Veteran, and provided an opinion. The examiner opined that while the Veteran's claim of getting lost in the jungle meets the criterion A to support a PTSD diagnosis, it was not related to the Veteran's fear of hostile military or terrorist activity. The examiner did not address the reported guerilla attack reported by the Veteran in August 2012. The Veteran submitted a private opinion dated in February 2017, wherein the examiner stated that the Veteran was diagnosed with PTSD using the DSM-V and discussed how the ambush evasion the Veteran partook while serving in Laos as well as becoming lost in the jungle was attributable to his PTSD. An October 2020 VA examiner provided the opinion that the Veteran has a mental health diagnosis of persistent depressive disorder (dysthymia) that was not incurred in or caused by military service. However, the VA examiner did not consider the February 2017 private medical opinion in rendering the opinion nor the claimed guerilla attack which the Veteran attributes to having been lost in the jungle. The Board finds that the October 2020 opinion report is inadequate because the examiners did not discuss all relevant evidence or consider the contentions of the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In addition, this examiner opined that neither the prior examinations documented PTSD as a primary diagnosis and further stated the February 2017 diagnosis of PTSD may simply indicate a temporary clinical presentation at the date of examination rather than a permanent diagnosis. However the requirement of the existence of a current disability can be satisfied when a veteran has a disability at the time he files his claim for service connection or during the pendency of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, a remand is necessary to obtain an addendum VA opinion. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of any PTSD. If the Veteran is diagnosed with PTSD, the clinician must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If the Veteran is diagnosed with a personality disorder and PTSD, then the clinician must opine whether the PTSD was at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. The clinician must opine whether the evidence of record including all lay statements and the Veteran's service records, corroborate the occurrence of a sexual assault (MST) in service. In offering this opinion, the examiner should discuss whether there are any markers, including but not limited to behavioral changes after the asserted assault to support the occurrence of MST. If the clinician finds that the evidence indicates that personal assault occurred during the Veteran's active service, the clinician must opine whether any acquired psychiatric disorder, to include PTSD, is at least as likely as not related to the in-service personal assault. The clinician's attention is invited to the letter from the Veteran's private physician dated February 2017 stating diagnosing the Veteran with PTSD in accordance with the DSM-5 criteria. The clinician's attention is invited to the Veteran's military service record documenting an excellent job performance review in April 1970. The clinician's attention is invited to the Veteran's service treatment records documenting a diagnosis of thrombosed hemorrhoid in May 1971. The clinician's attention is invited to the Veteran's military service record documenting his reassignment in July 1971. The clinician's attention is invited to the Veteran's military service record showing his demotion in rank in August 1971. All opinions provided must be thoroughly explained, and a complete and detailed rational for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The clinician is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. J. Kim, 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.