Citation Nr: 21040653 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 18-03 635 DATE: July 6, 2021 ORDER Service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED The issue of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded. FINDING OF FACT A VA psychologist confirmed that the Veteran's claimed stressor was adequate to support a diagnosis of PTSD. The claimed stressor is consistent with the places, types, and circumstances of his service. CONCLUSION OF LAW The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1979 to July 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from February 2016 and July 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a February 2021 video conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. § 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304 (f); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). In determining whether the Veteran has a current diagnosis of PTSD, the Board acknowledges that mental health professionals are experts, are presumed to know the DSM requirements applicable to their practice, and to have taken the DSM requirements into account in rendering a PTSD diagnosis. As such, a PTSD diagnosis provided by a mental-health professional must be presumed to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor, unless there is evidence to the contrary. See Cohen, 10 Vet. App. at 140. The evidence required to establish a claimed in-service stressor depends on the nature of both the stressor and the Veteran's service. If the evidence establishes a diagnosis of PTSD during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). In making all determinations, the Board must fully consider the lay assertions of record. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran contends he was crew chief in an UH-IH helicopter with Search and Rescue duties and was sent out on a mission that involved a plane crash. He reported that he still remembers the blood and dead bodies, that he was sent out on a lot of search and rescue missions, and that he still has a lot of bad memories. See May 2015 and October 2015 Statement in Support of Claim and February 2021 Board Hearing Transcript. Turning to the relevant evidence, service personnel records document that the Veteran had a military occupational specialty (MOS) of Utility Helicopter Repairer, which he performed for two years and seven months. Service medical records also document that the Veteran was medically qualified for flight duty. In a May 2015 Disability Benefits Questionnaire, the Veteran's treating psychologist noted that the Veteran served on search and rescue missions, determined that the Veteran met the criteria for PTSD, and diagnosed him with major depressive disorder and PTSD. The Veteran was afforded a VA PTSD examination in November 2015. The VA psychologist noted the Veteran's service history as a utility helicopter repairer. At the time of the examination, the Veteran reported that he went on search and rescue missions in service and during one mission, he was at a plane crash site and saw a dead pilot and blood everywhere. The VA psychologist determined that this stressor was adequate to support a diagnosis of PTSD and met Criterion A. The VA psychologist diagnosed the Veteran with PTSD. Given the foregoing, the Board finds that the Veteran's reported stressors are consistent with the circumstances of his service and the provisions of 38 C.F.R. § 3.304(f). There is no reason to doubt the credibility of the Veteran's lay statements, particularly given his PTSD diagnosis and the information in his service personnel records, which confirm a MOS of utility helicopter repairer. Accordingly, the Board finds the Veteran's reports of his in-service stressors and his PTSD symptoms thereafter both competent and credible. In addressing whether the Veteran's PTSD is related to service, the Board considers the November 2015 VA examination report to carry the greatest probative weight of the entirety of the evidence of record. The November 2015 VA psychologist indicated that the Veteran had experienced a traumatic event, principally, his work duties as a utility helicopter repairer and performing search and rescue missions, which satisfied criterion A for PTSD. The psychologist also noted the Veteran satisfied Criteria B through H and that he had PTSD symptoms of depressed mood, anxiety, and difficulty adapting to stressful circumstances including work or a worklike setting. The psychologist diagnosed the Veteran with PTSD under the DSM-V guidelines. The Board finds this determination to be highly probative, as it reflects consideration of all relevant facts. Furthermore, the PTSD assessments made by the VA psychologist are presumed to have been made competently. Cohen v. Brown, 10 Vet. App. 128, 140 (1997) (holding that absent evidence to the contrary, a PTSD diagnosis made by a mental-health professional is presumed to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor). Resolving doubt in favor of the Veteran, the claim of entitlement to service connection for PTSD is granted. 38 U.S.C. §§ 1131, 5107; see generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). REASONS FOR REMAND Entitlement to a TDIU is remanded. As a disability rating for the Veteran's service-connected PTSD, granted herein, has not yet been assigned, the Veteran's claim for a TDIU is remanded for further development. The Board further notes that the RO found the Veteran unemployable due to PTSD in its July 2016 rating decision. The matter is REMANDED for the following actions: 1. Ask the Veteran to file an updated VA Form 21-8940 detailing his work history throughout the appeal period. 2. Identify any outstanding records of pertinent medical treatment from VA or private health care providers. Follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159(c). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 3. After completing the requested actions, and any additional action deemed warranted, readjudicate the claim of entitlement to a TDIU. If the benefit sought on appeal remains denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board, if in order. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Bilstein, 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.