Citation Nr: 22044871 Decision Date: 08/08/22 Archive Date: 08/08/22 DOCKET NO. 17-53 032 DATE: August 8, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1991 to July 1993. The matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision. The Veteran had a hearing before the undersigned in May 2021. In February 2022, the Board remanded the matter for a VA medical opinion. Unfortunately, the Board finds that the obtained medical opinion is not adequate, and another remand is necessary. In April 2022, the VA examiner concluded the Veteran's psychiatric condition was less likely than not related to service. The examiner relied heavily upon on treatment records from 1994 and 1995, in which he reported pre-service abuse and mental health counseling. The examiner stated that "attempted suicide at age 14 with given Bipolar Disorder hx cannot be negated." However, as stated in the previous remand, the evidence does not clearly and unmistakably show the Veteran entered service with bipolar disorder. There is no competent evidence of a bipolar disorder diagnosis pre-service and his in-service and post-service records do not clearly and unmistakably show that he had bipolar disorder when he entered service. Thus, he is presumed sound at entrance. Accordingly, the matter must be remanded for a medical opinion that does not solely rely on the Veteran's pre-service symptoms. The matters are REMANDED for the following action: Forward the claims file to a VA examiner other than the examiner who completed the April 2022 medical opinion. An in-person examination is unnecessary unless determined otherwise by the examiner. The examiner is advised the Veteran is presumed sound based on his entrance examination, and although he may have had mental health symptoms prior to service, there is no competent evidence of a diagnosis. Aggravation is NOT at issue here. After a review of the claims file, the examiner should respond to the following: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's current psychiatric disorder began in or is otherwise related to service? The examiner should consider the entire claims file, to include the Veteran's service treatment records (which show treatment for insomnia, alcohol dependence), personnel records (which show a Chapter 14 separation for drug use), Ann Arbor and Saginaw VA mental health records from 1994 to 1998, the Dallas VA December 2013 treatment record, the May 2021 hearing transcript, and the Veteran's statements as documented in the March 2022 VA medical opinion (received April 6, 2022). For the purposes of the opinion, the examiner should assume the Veteran's statements about his symptoms are credible, unless they are inconsistent with the medical evidence or with medical principles concerning his condition(s). The Board emphasizes that this does not constitute a positive credibility determination, as the Board will weigh the evidence once the appeal returns. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. In doing so, the examiner may identify any discrepancies, inconsistencies, or contradictions contained in the evidence of record, and may state whether or not the Veteran's lay statements are supported by medical or other evidence. The Board notes that the Veteran's service entrance examination is located in the document titled Military Personnel Record, uploaded March 24, 2015. The Board also notes that the VA treatment records (dated July 2009 to January 2010) located in the SSA records in the claims file (uploaded September 15, 2021) do not belong to the Veteran. The remaining SSA records appear to be correct. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lavan 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.