Citation Nr: 25005393 Decision Date: 04/22/25 Archive Date: 04/22/25 DOCKET NO. 20-21 249 DATE: April 22, 2025 REMANDED Service connection for a psychiatric condition. ? REASONS FOR REMAND The Veteran served on active duty from June 1983 to May 1986. The case is on appeal from a June 2018 rating decision. In September 2021, the Veteran testified at a Board hearing. In July 2022, the Board reopened a claim for service connection for a psychiatric condition, denied a claim for service connection for a traumatic brain injury, denied an initial rating in excess of 10 percent for right ankle tendonitis, denied an initial compensable rating for superficial nonlinear scars of the right ankle, denied an initial rating in excess of 10 percent for a painful scar of the right ankle, and denied an effective date prior to January 26, 2018 for the award of service connection for right ankle tendonitis, two superficial scars of the right ankle, and a two painful scars of the right ankle. The Board also remanded claims for service connection for an abdominal disorder and a psychiatric disorder for additional development. In September 2023, the Veteran testified at an additional Board hearing. In April 2024, the Board denied the claim for service connection for an abdominal disorder and remanded the claim for a psychiatric condition for additional development. The Veteran appealed the July 2022 Board decision to the United States Court of Appeals for Veterans Claims (Court). In May 2024, the Court, issued a Memorandum Decision vacating the Board's decision that denied an initial rating in excess of 10 percent for right ankle tendonitis and service connection for a traumatic brain injury, and remanded the claims to the Board for further proceedings consistent with the Memorandum Decision. The Board will issue a separate decision concerning those issues. The Board notes that the Veteran's representative requested a hearing in correspondence received in August 2024. However, in October 2024, the Veteran revoked the representative's power of attorney and requested to withdraw the hearing request in December 2024. As such, the Veteran's hearing request is deemed withdrawn. 38 C.F.R. § 20.704(e). Service connection for a psychiatric condition. The Veteran is seeking service connection for a psychiatric condition. He asserts he has "psychological problems caused by suffering and mental trauma" caused during service. See November 2014 Statement in Support of Claim. The Veteran also asserts that his psychiatric condition is due to being forced out of the service after an altercation in the shower room that left him unconscious and with a concussion. The Veteran asserts further that as a result of the altercation, his rank was taken from him, and he was manipulated into leaving the Army early. See September 2021 Board Hr'g. Tr. at 1-3. At the second Board hearing, the Veteran's representative asserted that the Veteran should be evaluated for posttraumatic stress disorder (PTSD). She asserts that the Veteran's service records reflect that he was in an altercation and sought medical treatment six days after for a head contusion and as a result was demoted on March 20, 1986. The Veteran asserts that he is still suffering from the trauma of the attack. See September 2023 Board Hr'g. Tr. at 3, 7. However, the Veteran's service personnel records (SPRs) reflect that on February 19, 1986, an Article 15 procedure was initiated because on February 12, 1986, the Veteran failed to go at the time prescribed to his appointed place of duty. As a result of the proceedings, among other punishments, the Veteran received reduction in rank and forfeiture of pay. The results of the proceedings became final on March 20, 1986.The Veteran's SPRs also include a "Personnel Action" form dated on March 21, 1986, indicating that the Veteran requested an early release from his term of service, which was approved on March 21, 1986. The Veteran's STRs reflect that later, on March 26, 1986, he was seen in the clinic on base after an altercation earlier that day. The STRs state that the Veteran had a lump on his forehead and on the back of his head, because he was headbutted and hit the back of his head against the wall. At that time, there was no loss of consciousness noted and the Veteran was alert and oriented x 5. The Veteran was noted to have minimal edema in the central forehead and was diagnosed with a contusion of the forehead. Thus, although the records reflect the Veteran was in an altercation, they do not reflect that the Veteran was demoted or forced to leave the Army as a result of an altercation, as those incidents occurred in February 1986 prior to the altercation in March 1986. The Board remanded the claim in July 2022 for the provision of a VA examination and opinion concerning the Veteran's psychiatric diagnoses. Opinions were obtained in October 2022, February 2023, and April 2022. The Board finds that these opinions are not entirely adequate to decide the claim. In this regard, although diagnoses including schizoaffective disorder and borderline personality disorder were addressed, the examiners did not address whether the Veteran has PTSD. The examiner who provided the April 2022 opinion stated that although the Veteran has occasionally been diagnosed with PTSD, there is no comprehensive evaluation of PTSD in the claims file considering the full DSM-5 criteria are met and what the Criterion A event(s) the diagnosis relates to. As such, the examiner stated that PTSD was not considered an established diagnosis. As a result, as noted in the April 2024 Board remand reasons, the Board found an additional VA examination and opinion were warranted which addresses whether the Veteran is diagnosed with PTSD, or another psychiatric diagnosis, that is related to the in-service altercation. Pursuant to the Board's April 2024 remand directives, the Veteran was scheduled for examinations but failed to appear. In this regard, a VA examination was scheduled on May 2, 2024, however, the Veteran reported he was not notified of the examination. Another examination was scheduled on July 11, 2024, however, the claims file reflects that it appears the Veteran appeared for the examination on July 8, 2024 and reported there not an examiner at the appointment. An examination was also scheduled for August 5, 2024 but the Veteran did not appear. The Veteran provided a statement in December 2024 in which he explained that did not intentionally miss his examination as his phone did not have service for a period of time which resulted in his inability to confirm a time, date, and location for an examination. He also stated he is willing and able to attend a VA examination if one is scheduled. The Board is mindful of the provisions of 38 C.F.R. § 3.655 regarding action to be taken when a veteran fails to report for a scheduled VA examination. In this case, however, it is unclear whether the Veteran was properly notified of the May 2, 2024 VA examination, as a review of the claims file does not show that the Veteran was notified of this examination by either by VA or the third party contractor. Concerning the July 11, 2024 VA examination, it appears the Veteran did not report for the examination due to some confusion regarding the date of the examination. Concerning the August 5, 2024 VA examination, it is unclear whether he received notification of the examination as the claims file does not show that the Veteran was notified either by phone or in writing of this examination and he also reports that his phone did not have service during this time period. The Board notes that the Veteran has shown good cause for his failure to report to the rescheduled August 5, 2024 VA examination. In light of the foregoing, the Board finds that the Veteran should be afforded another opportunity to appear for a VA examination in connection with his claims since it appears he was not notified of the August 5, 2024 VA examination. The matters are REMANDED for the following action: Schedule the Veteran for a psychiatric examination to determine the nature and etiology of all psychiatric disorders. The examiner should review the entire claims file. The examiner should then address the following: Identify all of the Veteran's psychiatric disorders, to include whether he has met the criteria for PTSD. If PTSD is not diagnosed, it should be explained why this diagnosis is not appropriate. If the examiner finds that the Veteran meets the diagnostic criteria for PTSD, indicate whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the result of the claimed stressor(s). The Board notes that the claimed stressor is the fight that occurred in March 1968. The Veteran's STRs reflect that on March 26, 1986, he was seen in the clinic on base after an altercation earlier that day. The STRs state that the Veteran had a lump on his forehead and on the back of his head, because he was headbutted and hit the back of his head against the wall. At that time, there was no loss of consciousness noted and the Veteran was alert and oriented x 5. The Veteran was noted to have minimal edema in the central forehead and was diagnosed with a contusion of the forehead. The Board notes that contrary to his assertions, his personnel records to not reflect that he was demoted or forced to leave service as a result of this altercation. The examiner should consider the April 2022 VA opinion. The examiner should provide rationale for all opinions expressed, including by citing to the record. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gray, Elissa A. 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.