Citation Nr: 22018557 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 19-23 039 DATE: March 29, 2022 ORDER The application to reopen the previously denied claim of entitlement to service connection for schizophreniform disorder is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder to include schizophreniform disorder is remanded. FINDING OF FACT Newly obtained private medical records and testimony are material to the Veteran's claim for service connection for a schizophreniform disorder. CONCLUSION OF LAW New and material evidence has been received to reopen the claim of entitlement to service connection for a schizophreniform disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 10, 1986, to December 5, 1986. 1. Whether new and material evidence has been received to reopen a claim for service connection for a schizophreniform disorder. The Veteran seeks service connection for a schizophreniform disorder. The RO originally denied this claim in a December 1986 rating decision. The Veteran did not appeal that decision. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103 (2018). Therefore, the prior denial of service connection for schizophreniform disorder is now final, and the Veteran's claim for service connection may only be reopened if new and material evidence is received. "New" evidence means existing evidence not previously submitted to agency decision makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). When evaluating the materiality of newly-submitted evidence, the Board should not focus solely on whether the evidence remedies the principal reason for denial in the last prior decision, but rather should consider whether such evidence, in its entirety, could at least trigger the duty to assist by providing a medical opinion. See Shade, 24 Vet. App. at 117. Moreover, when determining whether a claim should be reopened, the credibility of any newly submitted evidence is to be presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The December 1986 final rating decision denied service connection on the basis that the Veteran's schizophreniform disorder began prior to service and was not aggravated by service. The December 1986 decision was based on the Veteran's service treatment records (STRs) and service personnel records. The STRs show that the Veteran was not noted to have a psychiatric disorder on examination for entry from service. Less than two months after entry he was hospitalized for a schizophreniform disorder. The Veteran reported that he had been hospitalized four years earlier at the University of South Alabama School of Medicine for a mental disorder. The Veteran was treated with medications and he responded well. The Veteran was noted to be competent and able to go home on his own. It was recommended that once he returned home that he seek continued follow up care. The medical evaluation board indicated that the Veteran's schizophreniform disorder existed prior to service and was not permanently aggravated by service. The evidence obtained since the final December 1986 rating decision includes the Veteran's hearing testimony that he was not hospitalized for any mental disorder prior to service. Also obtained were private medical records dated in March 2009 and July 2011 indicating that the Veteran first received psychiatric treatment during service. As the credibility of the newly received evidence is presumed only for purposes of reopening the claim and indicates that the Veteran first received psychiatric treatment during service, this evidence is material to the Veteran's claim. See Justus. Accordingly, new and material evidence has been received and the Veteran's request to reopen the claim for service connection for a schizophreniform disorder is granted. REASONS FOR REMAND 1. Entitlement to service connection for schizophreniform disorder. The record contains insufficient medical evidence to adjudicate the Veteran's claim. Medical evidence is needed to determine whether the Veteran's current psychiatric disability preexisted service, and, if so, whether it was aggravated by service. Although the record contains an inservice medical opinion, there is no post service medical opinion that considers the post service medical evidence. Accordingly, medical opinions must be obtained which consider both the inservice and the post service medical records. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991) and Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). The matter is REMANDED for the following action: 1. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 2. Provide the Veteran a VA examination with an appropriate examiner and obtain VA medical opinions to determine the nature and etiology of the Veteran's schizophreniform disorder and any other psychiatric disorder. a) The examiner must identify whether there is clear and unmistakable (obvious, manifest, or undebatable) evidence that the Veteran's schizophreniform disorder or any other psychiatric disorder preexisted his active duty service. b) If it is determined that the Veteran's schizophreniform disorder or any other psychiatric disorder clearly and unmistakably preexisted service, the examiner must state whether there is clear and unmistakable (obvious, manifest, or undebatable) evidence that the preexisting disorder was not aggravated beyond the natural progression of the condition during his active duty service. Note that the term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. c) If a schizophreniform disorder or any other psychiatric disorder is determined not to preexist service, the examiner should state whether it is at least as likely as not (i.e., 50 percent or greater probability) that such disorder is otherwise related to the Veteran's active duty service. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner 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. If the Veteran fails to report for the examination, the examiner must provide the requested opinions based on a review of the record. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Jones, 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.