Citation Nr: 21042274 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 13-34 909 DATE: July 12, 2021 REMANDED Entitlement to service connection for a right leg disability is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1988 to November 1990. The Veteran testified at a hearing before the undersigned Veterans Law Judge in February 2019. This matter was most recently remanded in November 2020. There has not been substantial compliance with the remand directives and the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). The claim must be remanded again to afford the Veteran another opportunity to submit any pertinent evidence related to in-service treatment for her right leg, to obtain any records related to a Social Security claim and to obtain an adequate medical opinion. Pursuant to the most recent remand, the Agency of Original Jurisdiction (AOJ) attempted to obtain in-service treatment records from Ft. McClellan, where the Veteran asserts she injured her right leg. The AOJ was ultimately unable to obtain those records. In correspondence dated March 30, 2021, the AOJ notified the Veteran of the inability to obtain the records and informed her that she could submit relevant records in her possession "as soon as you can." The AOJ then issued a supplemental statement of the case (SSOC) dated April 8, 2021 that continued the denial of the claim. Readjudication of the claim was premature, given the very recent notification to the Veteran (approximately one week prior) about the unavailability of service records and giving her information as to what evidence she could submit. The March 2021 VA examination was also premature, given that the AOJ had not yet completed the search for records or informed the Veteran of the outcome of that search. The opinion provided is also inadequate. The VA examination was conducted on March 5, 2021 and the examiner issued a negative nexus opinion, dated March 16, 2021. The rationale for the negative opinion is inadequate because it is based, in large part, on the absence of documented treatment for the right leg after service. The examiner did not consider the Veteran's lay statements of any continuing symptoms. That defect, and the fact that the Veteran was just recently notified of the unavailable records and the type of evidence she could submit, render the examination inadequate. It also appears that the Veteran is in receipt of disability benefits from the Social Security Administration (SSA). The record before the Board includes a letter from SSA stating that she is entitled to monthly disability benefits beginning in January 2014, but does not include any SSA records related to an award. To ensure VA has a complete record upon which to base its ruling, remand is also needed to obtain any outstanding SSA records. The matters are REMANDED for the following action: 1. Obtain the Veteran's federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 2. Contact the Veteran again and provide the information previously provided in the March 30, 2021 correspondence regarding the inability to find complete treatment records and evidence and information she could submit in connection with her claim. The Veteran should be afforded a specific time period within which to respond. 3. After completion of the foregoing, and after affording the Veteran a specifically identified period of time to respond to the above, obtain a medical opinion from an appropriate clinician on the nature and likely etiology of any diagnosed right leg disability. Copies of all pertinent records to an appropriate VA examiner to obtain a medical opinion for the Veteran's right leg disability claim. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled. The examiner must answer the following: (a) Identify all currently diagnosed right leg disabilities. (b) Is it at least as likely as not (50 percent probability) that any currently diagnosed right leg disability was incurred in or is otherwise related to service, to include an injury sustained from a 20-foot jump? Why or why not? The examiner is advised that the Veteran is competent to provide evidence of symptomatology readily apparent to him, regardless of whether the symptoms are noted in the service medical records or on the date of examination. The examiner may NOT rely on the absence of a medical record or evidence of medical treatment as the sole rationale for any negative medical nexus opinion. The examiner must provide reasons for each opinion given. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Jarman, 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.