Court Opinion

ID: 4879816
Source: CourtListenerOpinion
Date Created: 2021-08-27 23:00:41.100785+00
Date Added: 2024-06-11T08:12:42.275635
License: Public Domain

Citation Nr: AXXXXXXXX
Decision Date: 07/30/21	Archive Date: 07/30/21

DOCKET NO. 200506-82209
DATE: July 30, 2021

ORDER

Readjudication of the claim of service connection for an acquired psychiatric disorder, to include depression and anxiety, is granted.

REMANDED

Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety is remanded.

FINDING OF FACT

New evidence received after the February 2012 rating decision is relevant to the issue of entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety.

CONCLUSION OF LAW

The criteria for readjudicating the claim of service connection for an acquired psychiatric disorder, to include depression and anxiety, are met.  38 U.S.C. § 5108; 38 C.F.R. §§ 3.156(d), 3.2501(a)(1).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty with the United States Army from January 2000 to September 2007 and from October 2010 to November 2011.

In September 2019, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested review of a February 2012 rating decision based on new and relevant evidence.  In April 2020, the Agency of Original Jurisdiction (AOJ) issued the supplemental claim decision on appeal, which denied readjudication of the claim of service connection for an acquired psychiatric disorder, to include depression and anxiety because the evidence submitted was not new and relevant.

In the May 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), the Veteran elected the Direct Review option; therefore, the Board of Veterans' Appeals (Board) may only consider the evidence of record at the time of the AOJ decision on appeal.  38 C.F.R. § 20.301.  

VA will readjudicate previously denied claims if new and relevant evidenced is presented or secured.  See 38 C.F.R. § 3.156(d)).  Evidence not previously part of the actual record is new evidence.  38 C.F.R. § 3.2501(a)(1).  Relevant evidence is evidence that tends to prove or disprove a matter at issue in a claim.  Id.

The Veteran's claim of service connection for an acquired psychiatric disorder, to include depression and anxiety was initially denied in December 2007.  The AOJ reopened the claim of service connection for an acquired psychiatric disorder, to include depression and anxiety, and denied the claim on the merits in February 2012.  The February 2012 rating decision indicated there was no formal Axis I diagnosis, and the claim was denied because the evidence showed no permanent residual or chronic disability subject to service connection by service treatment records or evidence following service.  That decision became final as the Veteran did not file a timely Notice of Disagreement (NOD) or submit new evidence within one year.  38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103.

In September 2019, the Veteran submitted a supplemental claim requesting readjudication of the claim of service connection for an acquired psychiatric disorder.  VA treatment records added to the claims file in December 2019 demonstrate that current diagnoses of unspecified depressive disorder and unspecified anxiety disorder.  Private treatment records submitted in December 2019 indicate an additional diagnosis of adjustment disorder with anxious mood.    This evidence is new because the RO had no evidence of an Axis I diagnosis in the prior final denial.  The evidence is also relevant in that it tends to prove the first element of a claim of service connection requiring evidence establishing a current disability.  New and relevant evidence having been received, readjudication of the claim is warranted.

REASONS FOR REMAND

The Board is not able to make a fully informed decision on the issue of entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety.

As new and relevant evidence was received prior to the issuance of the AOJ decision on appeal, the failure of the AOJ to provide a VA examination or obtain a medical opinion constitute pre-decisional duty to assist errors and a remand is warranted.  38 C.F.R. § 3.159(c)(4)(iv).

Prior to the issuance of the AOJ decision on appeal, the Veteran and/or her Representative submitted a statement describing her psychological symptoms and contentions raising the theory of secondary service connection for an acquired psychiatric disorder, to include depression and anxiety, as proximately due to or aggravated by service-connected degenerative arthritis of the spine.  Accordingly, this theory of entitlement should be addressed upon remand.

The matters are REMANDED for the following action:

Schedule the Veteran for an examination with the appropriate clinician to determine that nature and etiology of any acquired psychiatric disorder.  The examiner must review the claims file in connection with the examination.

The examiner must identify any acquired psychiatric disorder diagnosed during the appeal period.  The examiner's attention is drawn to October 2007 to November 2008 VA treatment records pertaining to depression, anxiety, and adjustment disorder.

For each diagnosed condition, the examiner must opine as to whether such is at least as likely as not caused or aggravated by service.  The examiner must specifically acknowledge and consider the inservice complaints of insomnia, anxiety and loss of motivation treated with Paxil and Celexa.  

A full and complete rationale for all opinions expressed is required. 

 

WILLIAM H. DONNELLY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Ball Jackson, Associate 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.