Citation Nr: A24029712 Decision Date: 06/06/24 Archive Date: 06/06/24 DOCKET NO. 210121-130776 DATE: June 6, 2024 REMANDED Entitlement to service connection for a psychiatric disorder, to include paranoid schizophrenia, insomnia, and anxiety, is remanded. REASONS FOR REMAND The Veteran had active service from March 1989 to February 1993. This matter comes before the Board of Veterans' Appeals (Board) from a January 2021 rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office. In January 2021, the Veteran submitted a timely Decision Review Request: Board Appeal, VA Form 10182. He elected the Direct Review docket. Thus, the Board may only consider the evidence of record at the time of the Agency of Original Jurisdiction (AOJ) decision on appeal (i.e., January 20, 2021). 38 C.F.R. § 20.301. If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision. 38 C.F.R. § 20.300. Because this case is being remanded, any evidence that is not considered by the Board at this time will be considered by the AOJ upon readjudication of this claim. VA must provide a medical examination when there is (1) competent evidence of a current disability, or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. As an initial matter, the Board observes the AOJ provided the Veteran a VA psychiatric examination in August 1995, which was reviewed by the AOJ prior to issuing its May 1996 decision denying service connection for a psychiatric disorder. However, the full report of that examination is not available in the claims file; at least one page is missing. The Board reflects that there is not a formal finding of unavailability regarding the complete examination in this case. Moreover, it appears that the Veteran was hospitalized at the Brooklyn VA Medical Center at least twice in August and December 1994 for psychiatric symptoms, although some records from the December 1994 hospitalization appear of record, the Board notes that there does not appear to be a complete set of these records associated with the claims file. As these records and the 1995 examination report appear to be incomplete and there is no formal finding, a remand is necessary in order to obtain the full report and a complete set of records. Finally, in any event, in that prior examination, the Veteran disclosed first feeling depressed in 1992, while in active service. The Veteran initially applied for service connection for a psychiatric disorder in 1995 and again applied for service connection in January 2020, in which he indicated his psychiatric symptoms had worsened. Taken together, along with the fact that the previous examination report is not available in its entirety, the Board finds this evidence meets the low threshold to obtain a VA examination. A pre-decisional duty to assist in obtaining that examination requires a remand in order for such to be furnished at this time. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: 1. Obtain any and all VA treatment records, including any treatment at the Brooklyn VA Medical Center-as well as any in-patient hospitalization records from August and December 1994-and associate those documents with the claims file. If after attempts to obtain that complete VA treatment records, particularly from the Brooklyn VA Medical Center in 1994 are made and such is unavailable and further attempts to obtain such would be futile, such a finding should be noted in a Formal Finding of Unavailability that is associated with the claims file and the Veteran should be so notified. 2. Obtain a complete copy of the August 1995 VA Psychiatric examination report. If after attempts to obtain that complete report are made and such is unavailable and further attempts to obtain such would be futile, such a finding should be noted in a Formal Finding of Unavailability that is associated with the claims file and the Veteran should be so notified. 3. ONLY AFTER DIRECTIVES 1 & 2 HAVE BEEN ACCOMPLISHED: Schedule the Veteran for a VA examination to determine the nature and etiology of any psychiatric disorder(s). The claims folder must be made available to and be reviewed by the examiner. All tests deemed necessary should be conducted and the results reported in detail. After review of the claims file and examination of the Veteran, the examiner should then identify all of the Veteran's psychiatric disorders that meet, or have met, the DSM-5 diagnostic criteria throughout the appeal period. For each diagnosis, the examiner should opine whether such began during military service, within one year of discharge therefrom, or is otherwise the result of military service. In this regard, the examiner should address all statements regarding the onset of symptomatology and continuity of symptomatology since onset and/or since discharge from service. The examiner must specifically address the Veteran's diagnosis of schizophrenia in August 1995, as well as the course of symptoms that appear to place the beginning of those symptoms in approximately August 1994 or April 1994, within nearly one year from discharge. A complete rationale for all opinions expressed should be provided. MARTIN B. PETERS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Kuhns 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.