Citation Nr: 18160607
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 17-03 102
DATE:	December 27, 2018
REMANDED
Entitlement to service connection for depression is remanded.
REASONS FOR REMAND
The Veteran had active service from December 1987 to March 1992.	
 
Entitlement to service connection for depression is remanded.
After review of the record, the Board regrettably finds that a remand for further development is warranted. The Veteran maintains that his depression was incurred as the result of active service.  He is being treated for depression symptoms by his VA counselor. Post-service medical treatment notes dated in August 2015 first reflect treatment and diagnosis of depression and depression symptoms. Although the treating VA professional acknowledges the Veteran’s assertions that his depression symptoms are related to his active service and deployment overseas, no nexus opinion is given. 
VA’s duty to assist includes affording the claimant an examination or obtaining a medical opinion when there is competent evidence that a claimant has a current disability, or persistent or recurrent symptoms of a disability; there are indications that the disability may be associated with active service; and the record is insufficient to decide the claim. See 38 U.S.C. § 5103A(d) (2012). Under relevant VA regulations, action should be undertaken by way of obtaining a medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: 1) contains competent evidence of diagnosed disability or symptoms of disability; 2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, which may be established by competent lay evidence; and 3) indicates that the claimed disability may be associated with the in-service event, injury, or disease. 38 C.F.R. § 3.159 (c)(4) (2018). See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third prong of Section 3.159(c)(4), which requires that the evidence of record “indicate” that the claimed disability or symptoms may be associated with service, is a low threshold. To date, the Veteran has not been afforded a VA examination for his depression.
In light of the above considerations, the Board concludes that a medical examination and opinion is needed. Under these circumstances, evidentiary development is needed to fully and fairly evaluate the Veteran’s claim of service connection for depression. 38 U.S.C. § 5103A (2012). Thus, on remand, the Veteran must be afforded VA examination in order to obtain a current diagnosis based on both an examination and a thorough review of the claims file. Specifically, the Veteran must be afforded a full examination to determine any current relevant diagnosis found to be present—and to provide a medical nexus opinion with respect to any such disorder found.
The matter is REMANDED for the following action:
1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. Also, request that the Veteran identify any recent private treatment pertinent to his claim and provide information and authorization sufficient for VA to assist him in obtaining any pertinent medical records not yet associated with the record.
2. Upon receipt of all additional records, schedule the Veteran for a VA psychiatric examination. The record, including a copy of this remand, must be made available to the examiner for review, and the examiner must indicate in the examination report that the record was reviewed in conjunction with the examination, including for the history of this claimed disability.
All indicated tests and studies should be completed, and the examiner should take a complete history from the Veteran regarding his disabilities. Following completion of the examination and review of the claims file, the examiner must indicate whether it is at least as likely as not (50 percent probability or greater) that any psychiatric disorder found on examination, to include depression, was caused by, or is otherwise related to, his service.
In providing these opinions, the examiner must specifically address the post-service medical treatment records which note treatment for, and diagnosis of, depression as well as the Veteran’s assertions of depression as a result of active service.
The rationale for all opinions expressed must be provided. If the examiner is unable to provide the requested opinion, he or she must explain why the opinion cannot be provided.
3. After completing the above action, to include any other development deemed warranted, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim continues to be denied or is not granted to the Veteran’s satisfaction, send him a Supplemental Statement of the Case (SSOC) and give him an opportunity to respond to it before returning the file to the Board for further appellate consideration of the claim.
 
THERESA M. CATINO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	N. Peden, Associate Counsel

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