Court Opinion

ID: 5097385
Source: CourtListenerOpinion
Date Created: 2021-10-01 19:03:35.292349+00
Date Added: 2024-06-11T08:20:51.778299
License: Public Domain

Citation Nr: AXXXXXXXX
Decision Date: 08/31/21	Archive Date: 08/31/21

DOCKET NO. 200508-84979
DATE: August 31, 2021

REMANDED

Entitlement to service connection for an acquired psychiatric condition, to include posttraumatic stress disorder (PTSD) is remanded.

Entitlement to a compensable disability rating for traumatic brain injury (TBI) is remanded.

REASONS FOR REMAND

The Veteran had periods of active service from August 1985 to May 1988, from January 1995 to July 1995, and from September 2003 to September 2004.  These matters come before the Board of Veterans' Appeals (Board) on appeal from a Higher-Level Review rating decision issued in April 2020.  The Veteran has elected to have this case decided by direct review in a May 2020 VA Form 10182 Notice of Disagreement.

1. Entitlement to service connection for an acquired psychiatric condition, to include PTSD is remanded.

The Veteran was afforded a Compensation and Pension (C&P) examination in October 2019.  Though that examination indicated that the Veteran did not meet the DSM 5 diagnosis of PTSD, the examiner did make a diagnosis of "other specified trauma and stressor related disorder" but did not provide an opinion as to whether it was at least as likely as not that this condition was caused by the Veteran's service, including his service that resulted in a TBI or in his award of the Combat Infantryman Badge.  Consequently, the examination is not complete and reliance on an incomplete examination conducted prior to the decision is a duty to assist error.  This matter must therefore be remanded for an appropriate opinion.

2. Entitlement to a compensable disability rating for TBI is remanded.

In the Veteran's claim for his increased rating for residuals of a TBI, the Veteran reported that his symptoms were increasing in severity.  However, the Veteran was not provided with a VA examination of the current severity of his TBI or it's residuals.  Although there is an indication that a VA examination was scheduled and the Veteran failed to appear, the letter notifying the Veteran of the VA examination is not of record and as such, the Board cannot determine whether he had appropriate notice of the VA examination.  Consequently, the duty to assist was not complied with prior to the decision on appeal, and a remand is required to provide the Veteran with the required examination.

The matters are REMANDED for the following actions:

1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's diagnosed other specified trauma and stressor disorder is at least as likely as not related to the Veteran's service, including the events that led to his TBI.  It is noted that the Veteran is in receipt of the Combat Infantryman Badge.

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2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected TBI.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria.

 

 

TRACIE N. WESNER

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Steven H. Johnston, 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.