Citation Nr: 21041205 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 14-38 810 DATE: July 8, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1967 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board issued December 2018 and December 2020 decisions remanding the case for additional development including VA examinations. The RO issued a March 2021 rating decision granting service connection for a skin condition, and therefore that issue is no longer before the Board. The RO also issued a March 2021 supplemental statement of case (SSOC) denying service connection for an acquired psychiatric disability. 1. Entitlement to service connection for an acquired psychiatric disability is remanded. Although the Board is aware this case has been on appeal since September 2013 and additional delay is regrettable, an additional remand is necessary to allow the Board to make a fully informed decision regarding the Veteran's claim. In the December 2020 remand, the Board stated that the October 2019 VA examination was inadequate because the examiner based their opinion on a lack of documentation and failed to consider that the Veteran was subject to an Article 15 action while in service or his complaints of nerve trouble in 1970, within a year after separation of service, which might support the Veteran's contentions that he had continuous symptoms since service. Further, it was unclear if development had been completed. Therefore, the Board remanded the case and directed the RO to complete development and obtain a new medical examination. In a March 2021 VA examination, the examiner opined that the Veteran's mental health disorder was less likely than not caused by, or related to, his active service. In support of their opinion, the examiner stated that there was no evidence of any formal psychiatric complaints, findings, hospitalization, or treatment during service or within one year after discharge from service. In addition, the Veteran did not seek formal treatment until 2010, approximately 41 years after military discharge. The examiner failed to consider the Veteran's statements that his symptoms had been present since service, in combination with his 1970 claim for nerves, as stated in the Board directives. In addition, although the examiner stated that the Veteran's alcohol abuse disorder was separate and distinct from his depressive disorder, they stated they share many of the same symptoms including irritability, insomnia, and mood swings. The Veteran reported that he started drinking during service and service treatment records indicated he was diagnosed with insomnia and was subject to an Article 15 action due to disorderly conduct. The examiner discussed the Veteran's insomnia and Article 15 action, but opined they were isolated incidents based on the absence of any formal mental health condition or diagnosis in the Veteran's STRs. The Board finds the medical opinion does not substantially comply with the December 2020 remand directives, and therefore is inadequate. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding veterans are entitled to compliance with Board remand instructions). The matter is REMANDED for the following action: 1. Schedule the Veteran for a new VA examination from an appropriate clinician to determine the nature and etiology of the Veteran's mental health disorder. The claims file must be made available for review, and the examination report should reflect that such review occurred. After reviewing the claims file the examiner must: a. Discuss the Veteran's statements regarding his in-service symptoms and his reoccurring symptoms since service and document the Veteran's contentions in the examination report. b. Provide an opinion whether the Veteran's acquired psychiatric disability is at least as likely as not (50 percent or more) related to active service. If the examiner provides a negative opinion and relies on the absence of in-service treatment and/or diagnosis as dispositive, then the examiner must discuss Veteran's diagnosis of insomnia and the Article 15 disciplinary action during service, the Veteran's 1970 claim for service connection for nerves, and the Veteran's contentions of ongoing symptomatology. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles (Continued on the next page) involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Aubee, 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.