Citation Nr: 21042334 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-41 910 DATE: July 12, 2021 REMANDED Entitlement to service connection for chronic adjustment disorder, to include as due to military sexual trauma is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1979 to April 1980. In March 2021, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to service connection for chronic adjustment disorder, to include due to military sexual trauma VA has a duty to make reasonable efforts to assist Veterans in securing evidence necessary to substantiate their claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). The Veteran alleges entitlement to service connection for chronic adjustment disorder, to include as due to military sexual trauma; however, it appears that the Veteran was not provided the requisite notice compliant with 38 C.F.R. § 3.304(f)(5) explaining the types of evidence from sources other than the Veteran's service records that may corroborate her account of the alleged personal assault in service. Additionally, at the April 2017 VA examination, the Veteran reported that she receives disability payments from Social Security. However, there are no Social Security applications, decisions, or medical records associated with an SSA claim in the record. Where the record contains factual notice to VA that a Veteran may receive SSA benefits, VA has the duty to acquire a copy of the SSA records, including the decision granting SSA benefits and the supporting medical documentation, if they are relevant. SSA records are relevant if either (1) there is an SSA decision pertaining to a medical condition related to the one for which the Veteran is seeking service connection or (2) there are specific allegations "giv[ing] rise to a reasonable belief" that the SSA records may pertain to the claimed disability. Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); Baker v. West, 11 Vet. App. 163 (1998). As the SSA records may be relevant to the Veteran's service connection, 38 U.S.C. § 1151, increased rating, and effective date claims, any outstanding SSA records must be obtained and associated with the evidentiary record. The evidence also indicates that there may be outstanding relevant VA treatment records. Any VA treatment records are within VA's constructive possession, and are considered potentially relevant to the issues on appeal. As such, a remand is required to allow VA to obtain them. The matters are REMANDED for the following action: 1. Issue VCAA notice that is compliant with 38 C.F.R. § 3.304 (f)(5), which includes an explanation of the types of evidence from sources other than service records that may corroborate personal assault in service. Allow the appropriate time to respond. 2. Obtain the Veteran's VA treatment records, to include from the Vet Center. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and her representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. Requests for the records must continue until it is reasonably certain that further attempts would be futile. If the records are unavailable, the AOJ should associate a memorandum of unavailability with the claims file and notify the Veteran and his representative pursuant to the procedures outlined in 38 C.F.R. § 3.159(e). 3. Obtain from SSA all records pertaining to the Veteran's claim for disability benefits, if any, including copies of all medical records considered in deciding any claim. 4. After the above development is completed, schedule the Veteran for a VA examination with a VA psychiatrist or psychologist to determine the nature and etiology of any acquired psychiatric disorder. The claims file should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. With regard to each identified acquired psychiatric disorder present during the claim, the VA examiner must address the following: (a.) Is there clear and unmistakable (obvious, manifest, and undebatable) evidence that any psychiatric condition preexisted the Veteran's entry into military service? All records and medical principles that lead to any conclusion that a disorder clearly existed prior to service must be identified. (b.) If so, is there clear and unmistakable (obvious, manifest, and undebatable) evidence that the preexisting psychiatric condition was NOT aggravated by service? (c.) If there was an increase in severity of the Veteran's acquired psychiatric condition during service, was that increase clearly due to the natural progress of the disease, or was it above and beyond the natural progression? All records and medical principles that lead to any conclusion that a disorder was clearly not aggravated during service must be identified. (d.) If the Veteran's acquired psychiatric condition did not clearly and unmistakably preexist service, is it at least as likely as not (50 percent probability or greater) that any identified psychiatric condition had its onset during active service or is related to any incident of service, to include military sexual trauma? The examiner must specifically consider and discuss the Veteran's self-reported history and credible testimony that she experienced military sexual trauma in-service. The opinion and rationale should reflect such consideration. The examiner is also directed to consider the following: 1) the buddy statements from the Veteran's family; 2) the service treatment records noting depression, nervousness, and diagnosis of situational adjustment reaction; 3) the service personnel records reflecting satisfactory performance; and 4) the Veteran's testimony that she alleged homosexuality in order to obtain a discharge due to her in-service sexual assault. In providing the requested opinions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of possibility, but that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). (Continued on the next page) If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.