Citation Nr: 21042332 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-53 902 DATE: July 12, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1969 to October 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran requested a Board hearing that was scheduled for July 2018. Subsequently, in a July 2018 Statement in Support of Claim, the Veteran requested that his hearing be withdrawn. Accordingly, his request for a Board hearing is withdrawn. 38 C.F.R. § 20.704(e). This matter was previously before the Board in January 2019, wherein the Board remanded for a VA medical opinion. The matter has returned to the Board for adjudication. The Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include PTSD and anxiety disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran's VA treatment records also indicate other mental health diagnoses and as such, will be generalized broadly in the context of an acquired psychiatric disorder. The Veteran contends that he has an acquired psychiatric disorder with the onset during military service. Specifically, he states that he has PTSD in part, due to his daughter being abducted by her mother from Charleston Air Force Base. See February 2012 Statement in Support of Claim. Additionally, he states that he was left stranded in the Republic of Vietnam and had to ditch into the ocean from his plane. See April 2011 Statement in Support of Claim. The RO requested information regarding his stressor(s) in a May 2011 development letter. In September 2012, the RO determined that there was lack of information required to corroborate stressor(s) in connection to the Veteran's PTSD claim. See September 2012 VA Memorandum. The Veteran listed other stressors in his September 2013 NOD to include being hit in the face as a bystander with an aluminum can that broke two front teeth and conflicts with his supervisor in March and June 1971. Service dental records show that he was treated for fractures of teeth 8, 9, 10 from a fall in July 1969. The Veteran's service treatment records (STRs) show that he was involved in an altercation with his immediate section chief in March 1971. In June 1971, the Veteran had a recurrence of stomach discomfort after emotional trauma at work due to some conflict with a supervisor. As such, the Board finds that these two stressors have been verified. On remand, the RO should attempt to verify the Veteran's in-service stressors relating to the abduction of his daughter and being stranded in Vietnam. The Veteran was afforded a VA examination in September 2012. The January 2019 Board decision remanded the issue as it found that the September 2012 VA examination report was speculative and lacked rationale. The VA examiner opined that it is less likely than not that the Veteran's anxiety disorder is due to noncombat experiences during active service as the Veteran described numerous stressor incidents that occurred prior to and after service that could be contributing to the current anxiety disorder. The Board also found that the VA examiner did not address the Veteran's STRs that showed the Veteran was treated multiple times for anxiety during service, which treatment included prescription medication and emergency treatment with mild tranquilizers, and during a September 1973 separation examination, the Veteran reported nervous trouble due to the Air Force environment. The Board directed the RO to request a VA medical opinion regarding service connection for an acquired psychiatric disorder. In this regard, the Board noted that if the VA examiner determines that additional examination(s) of the Veteran is necessary to provide reliable opinions as to causation, such examination(s) such be scheduled; however, the Veteran should not be required to report for an examination as a matter of course, if it is not found to be necessary. The Veteran was scheduled for a VA examination in October 2019 but failed to report for the examination. A review of VA treatment records show that the Veteran was in long term care at the VA during this time as he needed care for his activities of daily living and cognitive issues. See October 2019 VA treatment records. The RO has been determined that the Veteran is incompetent from December 2015. VA treatment records show that the Veteran lacks capacity and is unable to participate within discussion of his health care. See May 2020 VA treatment record. Here, the Board finds a VA medical opinion should be obtained without examination of the Veteran, given the circumstances involving his declining cognitive state and possible inability to travel to a VA examination site. However, if the Veteran is receiving care at a VA facility, an examination should be scheduled at that specific VA Medical Center, if at all feasible. The Board emphasizes that if an examination of the Veteran cannot take place, the RO must obtain a medical opinion based on review of the records. The matters are REMANDED for the following action: 1. Obtain VA treatment records from June 2020 to present. All reasonable attempts should be made to obtain any identified records. 2. The RO should attempt to substantiate the Veteran's claimed stressors regarding his daughter being abducted by her mother from Charleston Air Force Base and being stranded in the Republic of Vietnam. All records and responses must be detailed and associated with the claims file. 3. After completion of the above and regardless of whether the above two stressors have been verified, obtain a VA medical opinion from a qualified medical professional to address the claim for an acquired psychiatric condition. (The Veteran listed other stressors in his September 2013 NOD to include being hit in the face as a bystander with an aluminum can that broke two front teeth and conflicts with his supervisor in March and June 1971. Service dental records show that he was treated for fractures of teeth 8, 9, 10 from a fall in July 1969. The Veteran's service treatment records (STRs) show that he was involved in an altercation with his immediate section chief in March 1971. In June 1971, the Veteran had a recurrence of stomach discomfort after emotional trauma at work due to some conflict with a supervisor.) The decision for an in-person examination of the Veteran is left to the discretion of the examiner. If the examiner determines that an examination is necessary and the Veteran is receiving care at a VA facility, an examination should be scheduled at that specific VA Medical Center, if at all feasible. However, if the Veteran is unable to report for a VA examination, a medical opinion based on review of the Veteran's record must be obtained. The Veteran's record, to include a copy of this remand, should be made available to and reviewed by the examiner, and an opinion as follows is requested: a) The physician should clearly identify any psychiatric disability(ies), currently present, or present at any point pertinent to the current claim (even if now asymptomatic or resolved) and clearly state whether the disability(ies) is a current or resolved diagnosis. b) For each diagnosis, is it at least as likely as not (a 50 percent or greater probability) that the psychiatric disorder had an onset in service or otherwise related to active service. c) If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether the PTSD is at least as likely as not related to related to the Veteran's confirmed stressor(s). The examiner must also determine if any comorbid psychiatric disorders are related to the diagnosis of PTSD and explain whether the symptoms from the other mental health conditions can be separated or are intertwined from those symptoms related to the PTSD diagnosis. In rendering the above opinions, the VA examiner must consider and discuss the Veteran's STRs that document mental health issues throughout service. In considering any lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examination report must include a complete rationale for any opinion provided. If the examiner cannot provide the requested opinion without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. 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.