Citation Nr: 24010682 Decision Date: 03/05/24 Archive Date: 03/05/24 DOCKET NO. 20-24 301 DATE: March 5, 2024 REMANDED Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and depression, is remanded. REASONS FOR REMAND The Veteran had active service from August 1978 to March 1983 in the United States Marine Corps (USMC). This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2018 rating decision issued by the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In August 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board finds that additional development is necessary before the claim on appeal is decided. A March 2018 VA treatment record indicated that the Veteran was seeing a private physician, Dr. J.K. at Steward Medical Group. It was also noted that treatment records from Dr. J.K. dated in February 2018 were scanned into VistA Imaging, VA's electronic healthcare records system. Those records, however, were not provided. Therefore a remand is necessary so that the records can be associated with the Veteran's claims file. During the August 2021 Board hearing, the Veteran stated that he first sought treatment from a private psychiatrist, Dr. A.O., at St. Elisabeth's hospital in 1997. The Board finds that a remand is necessary so that an attempt can be made to obtain those records. The Veteran maintains that his current psychiatric disability is related to two stressful events that occurred during service while he was attached to the presidential helicopter squadron (HMX-1): 1) In April 1982, his unit landed on a small island in the Bahamas to refuel and a person came out of the woods with a M-16; he was unarmed and defenseless and believed he was going to be shot and killed; and 2) In October 1992, a fuel truck filter came apart, fuel rushed onto the flightline towards Air Force One and Marine One; the flightline had to be foamed and the aircraft moved; he was interrogated by the base command, secret service, and FBI; and he thought he was going to jail and that his career was done. The AOJ attempted to verify the second stressor related to the fuel spill but was informed that no records were found for HMX-1 dated from July 1982 to December 1982. There is no indication that any attempts were made to verify the first stressor pertaining to the armed gunman who came out of the woods. Therefore, the Board finds that a remand is necessary so that an attempt can be made to corroborate the claimed stressor. Furthermore, an August 2021 VA treatment record indicated that the Veteran's treating psychiatrist diagnosed the Veteran with PTSD and depression not otherwise specified. The provider indicated that the diagnosis of PTSD was clearly based on his exposure to the two traumatic incidents related above. Therefore, the Board also finds that the Veteran should be afforded a VA examination. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records, to include records from Dr. A.O. at St. Elisabeth's hospital; Dr. J.K. at Steward Medical Group; and the private treatment records that were scanned into VistA imaging dated in February 2018. If a complete copy of the records is unavailable in VistA imaging display, obtain the records directly from the facility and associate the with the claims file. 2. Conduct the appropriate development to verify the Veteran's claimed PTSD stressor through official sources and appropriate repositories of such information. Specifically, the AOJ should verify whether an armed gunman approached HMX-1 while attempting to refuel in April 1982. All attempts to verify the reported stressor must be documented in the claims file. 3. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any psychiatric disorder that may be present. Any indicated studies should be performed. After examining the Veteran, and considering his pertinent medical history and lay statements regarding reported symptoms, the examiner should identify all psychiatric disorders that are present. For each diagnosis identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disorder manifested during active service or is otherwise causally or etiologically related to his active service. With respect to PTSD, the examiner should determine whether the diagnostic criteria to support a diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the current symptomatology is causally or etiologically related to any verified in-service stressor. A rationale for all opinions expressed must be provided. 4. Confirm that the VA examination report and all opinions provided comport with this remand, and undertake any other development found to be warranted. 5. Then, readjudicate the issue on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.