Citation Nr: 21032833 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 18-12 109 DATE: May 28, 2021 THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REMANDED Entitlement to service connection for PTSD is remanded. REASONS FOR REMAND This case comes before the Board of Veterans' Appeals (the Board) from a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran appeared at a Board video-conference hearing in January 2021 before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran's claims file. Entitlement to service connection for PTSD is remanded. The Veteran contends that his claimed PTSD is related to his service. See January 2021 Board hearing. The Board cannot make a fully informed decision on the issue of entitlement to service connection for his claimed disabilities because no VA examiner on record has opined as to whether this condition is related to the Veteran's service. The RO originally denied the Veteran's claim to service connection for PTSD because the Veteran's claimed in-service stressor could not be corroborated. See January 2018 Statement of the Case (SOC). The Veteran claimed that he witnessed the death of a fellow service member from a parachuting accident at Ft. Bragg. In support of this contention, Veteran has submitted a buddy statement received by VA in May 2014. The May 2014 buddy statement, written by Mr. R.S., indicates that the author witnessed the claimed event and that the Veteran was present. Additionally, the Veteran submitted a news article which details a fatal parachuting accident on October 27, 1981 at Ft. Bragg. The Veteran has not been afforded an examination for his claimed PTSD. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2014). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed.Cir. 2003). The Board, therefore, finds VA has a duty to provide VA examination and obtain a medical opinion for the Veterans claimed PTSD under the low threshold of McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Finally, the Board notes that significant parts of the Veteran's service treatment records appear to be missing. Where STRs have been destroyed or are unavailable, VA has a heightened duty to assist the Veteran. See O'Hare vs. Derwinski, 1 Vet. App. 365 (1991). That duty includes obtaining medical records and medical examinations where indicated by the facts and circumstances of the individual case. Littke v. Derwinski, 1 Vet. App. 90 (1990). Although it appears that VA undertook some efforts to obtain the Veteran's service treatment records, upon remand, VA should make an additional attempt to locate the relevant service records, including the Veteran's service treatment records. See 38 C.F.R. § 3.159 (c) (2). Therefore, a remand is necessary to obtain the above-mentioned records and to schedule the Veteran for a VA psychological examination. The matters are REMANDED for the following action: 1. Conduct a search by all appropriate means to identify and obtain complete service treatment records. All attempts to secure this evidence, to include any negative response, must be documented in the claims file. In compliance with 38 C.F.R. § 3.159 (c) (2), the AOJ must make as many requests as are necessary to obtain records in the custody of a Federal department or agency and shall not end its efforts to obtain those records unless it concludes that the records sought do not exist or that further efforts to obtain those records would be futile. If after all procedurally appropriate actions to locate and secure the records have been made and the AOJ concludes that such records do not exist, that further efforts to obtain the records would be futile, the AOJ must make a formal finding to that effect. The AOJ must notify the Veteran of (a) the identity of the specific records that cannot be obtained, (b) an explanation as to the efforts that were made to obtain those records, (c) a description of any further action to be taken by VA with respect to the claims, and (d) notice that the Veteran is ultimately responsible for providing the evidence. 38 C.F.R. § 3.159 (e). The Veteran must then be given an opportunity to respond. Attempts should be made to obtain identified records. All attempts to fulfill this development should be documented in the claims file. 2. After completing the first directive, schedule the Veteran for a VA examination with a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, to determine the nature and etiology of the Veteran's claimed PTSD. The request should include the details and nature of the Veteran's claimed stressor of witnessing the demise of a fellow service member during a parachuting accident. The electronic claims file, to include the Veteran's service treatment records, lay statements, January 2021 Board hearing transcript, and treatment records, must be reviewed by the examiner. The VA examiner's opinion should specifically address the following: (a) Diagnose all current psychiatric disabilities and provide a full multi-axial diagnosis under the diagnostic criteria found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Specifically state whether or not each criterion for a diagnosis of PTSD is met pursuant to the DSM-V. (b) If a diagnosis of PTSD is found, state whether the claimed corroborated stressors support the diagnosis of PTSD, and state whether it is at least as likely as not (i.e., probability of 50 percent or greater) that PTSD is related to the claimed stressors? A complete explanation must be provided for all opinions. The examiner 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 dived 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. Any opinions offered should be accompanied by the underlying reasons for the conclusions. If the examiner is unable to offer any of the requested opinions, a rationale should be provided for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 3. After the above, readjudicate the claim on appeal, and furnish the Veteran and his representative a supplemental statement of the case if a matter is not resolved to the Veteran's satisfaction. Provide an opportunity to respond before the case is returned to the Board. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Geary, 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.