Citation Nr: 25003672 Decision Date: 03/18/25 Archive Date: 03/18/25 DOCKET NO. 14-38 496A DATE: March 18, 2025 REMANDED Entitlement to service connection for schizophrenia is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1979 to August 1979. This matter is before the Board of Veterans' Appeals (Board) on appeal from the April 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decision that reopened the Veteran's claim based on receipt of new and material evidence and continued the denial of entitlement to service connection for schizophrenia. The April 2013 rating decision stemmed from an October 2012 claim. This matter was previously before the Board when it remanded this issue in May 2018, January 2022, August 2022, and December 2022. In November 1979, the Veteran filed an initial claim for service connection for "aggravation of pre-existing nervous condition." In a March 1980 rating decision, the RO denied service connection for schizophrenia. Next, in July 1987, the RO denied the Veteran's June 1987 request to reopen the claim based on new and material evidence. In August 1987, the Veteran appealed the RO's July 1987 decision to the Board. In a November 1987 decision, the Board adjudicated the Veteran's claim on the merits and denied service connection for schizophrenia. Then, in an April 1994 rating decision, the RO denied the Veteran's March 1994 request to reopen his claim for service connection for schizophrenia because the Veteran failed to submit new and material evidence. Next, in a January 1997 rating decision, the RO denied the Veteran's August 1996 request to reopen his claim for service connection for schizophrenia because the Veteran failed to submit new and material evidence. In October 2009, the Veteran filed a VA Form 21-526 claim for service connection for schizophrenia. In a January 2010 rating decision, the RO continued its previous denial because it determined that the Veteran did not submit new and material evidence. In an April 2010 rating decision, the RO denied the Veteran's February 2010 request to reopen the claim because the Veteran had not submitted new and material evidence. Then, in October 2012, the Veteran filed another VA Form 21-526 claim for service connection for schizophrenia from which, as previously discussed, the appeal currently before the Board arose. In a July 2023 decision, the Board denied the Veteran's claim for entitlement to service connection for schizophrenia. The Veteran then appealed the Board's July 2023 denial to the United States Court of Appeals for Veterans Claims (Court). In October 2024, the Court vacated the Board's July 2023 decision for action consistent with the terms of the parties' Joint Motion for Remand (JMR). The Board is obligated by law to ensure that the Agency of Original Jurisdiction (AOJ) complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). AOJ compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Id. The December 2022 Board remand directed the AOJ to obtain an addendum opinion addressing specific questions related to the Veteran's schizophrenia disability and the presumptions of soundness and aggravation. January and February 2023 VA addendum opinions addressed these questions as directed. Thus, the Board finds that the AOJ substantially complied with the December 2022 Board remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999), aff 'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Entitlement to service connection for schizophrenia is remanded. In a March 2023 brief, the Veteran's attorney argues that the Veteran's schizophrenia was not a preexisting condition when he entered active service; and therefore, the presumption of soundness applies. The Veteran's attorney contends that VA has not met its burden to show by clear and unmistakable evidence both that the Veteran's schizophrenia preexisted his entrance into service and that it was not aggravated by service. In the October 2024 JMR, the parties agreed that the Board erred when it failed to ensure VA satisfied its duty to obtain outstanding private treatment records necessary to substantiate the Veteran's claim for benefits. 38 U.S.C. § 5103A(a)(1); 38 C.F.R. § 3.159(c)(1). As previously discussed, in his November 1979 VA Form 21-526 claim, the Veteran applied for service connection for "nerves" and reported that he received treatment in 1977 at Valley Psychiatric Hospital for "nerves." During a March 1980 VA examination, the Veteran stated that he had been hospitalized at Valley Psychiatric Hospital for five months in 1977. He reported that he had a "nervous condition" and was prescribed Thorazine. In a November 1987 decision, the Board denied service connection for schizophrenia and found that "records became available from the Valley Psychiatric Hospital Corporation." The Veteran's July 1979 physical evaluation board (PEB) report and September 2022 VA examination note medical documentation showing that the Veteran was hospitalized at Valley Psychiatric Hospital and treated at Erlanger Hospital in August 1977. The July 1979 PEB report, November 1987 Board decision, and a December 2021 VA treatment note all report medical records documentation that the Veteran was treated at Valley Psychiatric Hospital for an "acute psychotic episode" in 1977. However, the Veteran's medical records from Valley Psychiatric Hospital and Erlanger Hospital are not in his claims file. The parties to the JMR agreed that the Veteran adequately identified where he was treated, when he was treated, and the condition for which he was treated. Therefore, VA failed to satisfy its duty to assist the Veteran in obtaining these records. 38 C.F.R. § 3.159(c)(1). As a result, remand is warranted for VA to attempt to obtain these records and then reassess the presumptions of soundness and aggravation. Furthermore, the Board finds that remand is also necessary to obtain outstanding service treatment records related to the Veteran's claim. The evidence of record shows that the Veteran was admitted to Naval Regional Medical Center, Camp Lejeune in June 1979 to for inpatient psychiatric treatment for schizophrenia. However, the Veteran's file does not include these inpatient hospital records nor is there evidence that VA attempted to obtain them after the Veteran requested them. June 12, 1979 service treatment records (STRs) show that the Veteran received "treatment r/o schizophrenia" at "NRMC, CLNC" (Naval Regional Medical Center, Camp Lejeune, NC). July 1979 STRs show that the Veteran's PEB recommended that he be discharged from service due to his schizophrenia diagnosis. The PEB found that his schizophrenia existed prior to his entry on active duty and was not aggravated by service. The PEB report included a summary of the Veteran's course of inpatient psychiatric treatment while admitted to Naval Regional Medical Center, Camp Lejeune. However, the Veteran's inpatient hospital records are not included with the PEB report. On his November 1979 VA Form 21-526 claim, the Veteran indicated that he received medical treatment in July 1979 at Camp Lejeune, NC for a "nervous condition." In a March 1980 statement, the Veteran discussed that he was hospitalized for schizophrenia and put on medication at the Naval hospital at Camp Lejeune. The Veteran also specifically requested a copy of his hospital records from this inpatient treatment. However, there is no evidence that VA ever requested or otherwise attempted to obtain these specific inpatient hospitalization service treatment records. During a March 1980 VA examination, the Veteran stated that he had been hospitalized at Camp Lejeune for about three months before he was discharged from active service in August 1979. The VA examiner noted that the Veteran was treated on a "psychiatric ward" at Camp Lejeune hospital for schizophrenia. In a March 1980 rating decision, the RO found that the Veteran's military medical records showed that he was hospitalized in June 1979 upon a diagnosis of schizophrenia, catatonic type. In November 1987 and July 2023 decisions, the Board referenced as evidence the Veteran's STRs that showed he was admitted to Naval Regional Medical Center, Camp Lejeune in June 1979, and the July 1979 PEB report's summary of the Veteran's inpatient psychiatric unit treatment. However, the records from the Veteran's inpatient psychiatric hospitalization are not in his claims file. Based on a review of the record, the Board finds that the Veteran adequately identified and specifically requested his 1979 psychiatric inpatient hospitalization service treatment records from Naval Regional Medical Center, Camp Lejeune. These records have a reasonable possibility of substantiating his claim for service connection for schizophrenia. Therefore, remand is warranted for VA to satisfy its duty to assist the Veteran in obtaining these outstanding service treatment records. 38 U.S.C. § 5103A(a)(1); 38 C.F.R. § 3.159(c)(2)-(3). The matters are REMANDED for the following action: 1. Provide the Veteran and his representative with VA Form 21-4142 Authorization to Disclose Information to the Department of Veterans Affairs for consent to obtain the Veteran's 1977 records from both Erlanger Hospital and Valley Psychiatric Hospital in Chattanooga, TN. Document and associate with the claims file all attempts to obtain these records and any determinations made regarding the availability of these records. (Continued on next page) ? 2. Request the Veteran's June-August 1979 Naval Regional Medical Center, Camp Lejeune, NC psychiatric inpatient hospitalization records. Document and associate with the claims file all attempts to obtain these records and any determinations made regarding the availability of these records. J. Abrams Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Heely, Johanna L. 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.