PSYCHIATRIC DISORDER

Summary

The veteran, who served from February 1989 to April 1992, including service in Saudi Arabia and receipt of a Combat Infantryman Badge (CIB), appeals the denial of service connection for a psychiatric disorder. The Board recharacterized the claim to include PTSD and polysubstance use disorder. The veteran's claim was initially denied in January 2016, but a supplemental claim was filed in February 2020, accompanied by a private positive nexus opinion in June 2024. This new evidence, a August 15, 2022 private opinion, was considered new and relevant, leading to the reopening of the claim. The Board found the veteran engaged in combat, verified by his lay testimony and CIB award, satisfying the stressor element for PTSD. A December 2015 VA examination was deemed inadequate as it failed to consider the Veteran's May 2015 PTSD diagnosis from Landmark Counseling Services. The Board found a August 2022 private medical opinion highly probative, as it was based on an accurate factual premise, included a clinical interview, detailed the in-service stressor, and provided a favorable nexus opinion stating the PTSD and polysubstance use disorder were at least as likely as not incurred in service. This opinion was uncontradicted. Applying the benefit of the doubt doctrine, service connection for PTSD and polysubstance use disorder was granted.

Full Decision Text

Citation Nr: A26031228
Decision Date: 04/06/26	Archive Date: 04/06/26

DOCKET NO. 200507-269099
DATE: April 6, 2026

ORDER

New and relevant evidence having been received, readjudication of service connection for a psychiatric disorder is granted.

Service connection for posttraumatic stress disorder (PTSD) and polysubstance (alcohol, cocaine, and tobacco) use disorder (hereinafter PTSD) is granted.

FINDINGS OF FACT

1. Evidence received since the January 2016 rating decision is new and relevant to the claim of service connection for a psychiatric disorder.

2. The Veteran has been diagnosed with PTSD based on a combat-related in-service stressor.

CONCLUSIONS OF LAW

1. New and relevant evidence has been received for readjudication of the service connection claim for a psychiatric disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.2501.

2. The criteria for service connection for PTSD are met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from February 1989 to April 1992, to include service in Saudi Arabia. He was awarded a Combat Infantryman Badge (CIB), among other decorations.

This case comes before the Board of Veterans' Appeals (Board) from an April 2020 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), hereinafter the Agency of Original Jurisdiction (AOJ), which declined to reopen the claim for service connection for a psychiatric disorder on the basis that new and relevant evidence was not received. In May 2020, the Veteran submitted a timely Board Appeal: Notice of Disagreement (NOD), VA Form 10182, identifying issues decided in that decision, and electing the Hearing docket.

A hearing with a Veterans Law Judge was held on April 8, 2024; a transcript of the hearing is of record. Because the Veteran elected the Hearing docket, the Board may only consider the evidence of record at the time of the notification of the AOJ decision on appeal (April 24, 2020), as well as any evidence submitted by the Veteran at the hearing and within 90 days of the hearing (April 8, 2024 through July 8, 2024). 38 C.F.R. § 20.302. The Board cannot consider (1) evidence submitted during the period after the AOJ promulgated and issued the decision on appeal and before the hearing was held (April 25, 2020 through April 7, 2024), or (2) evidence submitted more than 90 days after the hearing was held (on or after July 9, 2024). 38 C.F.R. § 20.302. If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision. 38 C.F.R. § 20.300.

The Board notes that the Veteran filed a claim for service connection for PTSD. Nevertheless, as the record notes another psychiatric diagnosis, the Board has expanded the Veteran's claim to include all psychiatric disabilities, and the issue has been recharacterized as stated on the title page. Clemons v. Shinseki, 23 Vet. App. 1 (2009).

As a final initial matter, the Board notes that the Veteran's representative requested a copy of the December 2015 VA examiner's curriculum vitae (C.V.) because the AOJ relied upon the examination is denying this claim, which was never provided. See April 2024, June 2024, and August 2024 Correspondence from the Veteran's Representative, and July 19, 2024 VA Response Letter. However, as this case is being granted in full, there is no prejudice to the Veteran in not providing that document. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).

New and Relevant Evidence

Under the AMA, "if new and relevant evidence is presented or secured with respect to a supplemental claim, the Secretary shall readjudicate the claim taking into consideration all of the evidence of record." 38 U.S.C. § 5108(a); 38 C.F.R. §§ 3.156, 3.2501. New evidence is defined as "evidence not previously part of the actual record before agency adjudicators." 38 C.F.R. § 3.2501(a)(1). Relevant evidence is defined as "evidence that tends
 providing that document. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).

New and Relevant Evidence

Under the AMA, "if new and relevant evidence is presented or secured with respect to a supplemental claim, the Secretary shall readjudicate the claim taking into consideration all of the evidence of record." 38 U.S.C. § 5108(a); 38 C.F.R. §§ 3.156, 3.2501. New evidence is defined as "evidence not previously part of the actual record before agency adjudicators." 38 C.F.R. § 3.2501(a)(1). Relevant evidence is defined as "evidence that tends to prove or disprove a matter in issue" and includes evidence that raises a theory of entitlement that was not previously addressed. 38 C.F.R. § 3.2501(a)(1).

The Veteran's claims for service connection for a psychiatric disorder was initially denied in a rating decision in January 2016.

The Veteran then filed a supplemental claim in February 2020. In June 2024, the Veteran submitted an August 15, 2022 private positive nexus opinion for a psychiatric disorder.

The August 2022 private opinion did not exist at the time of the January 2016 rating decision, and therefore could not have been considered by the AOJ. The private opinion is relevant as it tends to prove or disprove a matter at issue (i.e., any of the elements of the claim of service connection). Accordingly, the claim for service connection for a psychiatric disorder is reopened at this time. 38 U.S.C. § 5108; 38 C.F.R. § 3.2501.

Service Connection

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

As an initial matter, the Board finds that the Veteran engaged in enemy combat during his military service. The Veteran has competently reported engagement in gunfire with the enemy in support of troops near the border of Iraq while stationed in Saudi Arabia. See, e.g., April 2024 Board Hearing Transcript. Personnel records confirm that the Veteran served in Saudi Arabia and received the CIB award at that time for his service. See Military Personnel Records (showing a March 19, 1991 CIB Award and service from September 1990 to March 1991 in Saudi Arabia).

Next, establishing entitlement to service connection for PTSD requires (1) medical evidence diagnosing PTSD; (2) a link, established by medical evidence, between a Veteran's present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Of note, and as is relevant here, in cases of combat service, a Veteran's stressor may be verified by lay evidence. 38 C.F.R. § 3.304(f)(2).

In this case, the Veteran was diagnosed with PTSD and polysubstance use disorder under the DSM-5, based on his reported in-service stressor of a firefight while stationed in Saudi Arabia. See August 2022 Private Medical Examination and Opinion. 

Additionally, the Veteran sought treatment for his mental health issues in May 2015 and was diagnosed with PTSD at that time. See May 2015 Landmark Medical Treatment Records. While the May 2015 medical records do not elucidate how the examiner arrived at the diagnosis of PTSD, i.e. they do not show that the diagnosis was based on his in-service stressor of a firefight, they do make references to his military service throughout the report.

In this regard, the Board also acknowledges the December 2015 VA Initial PTSD Examination, which does not show a diagnosis of PTSD; however, the Board finds this examination inadequate. The examination states that there is no evidence of mental health related evaluations and treatment, but the claims file contains the May 2015 Landmark Counseling Services records showing a diagnosis of PTSD, and these records were associated with the claims file prior
 See May 2015 Landmark Medical Treatment Records. While the May 2015 medical records do not elucidate how the examiner arrived at the diagnosis of PTSD, i.e. they do not show that the diagnosis was based on his in-service stressor of a firefight, they do make references to his military service throughout the report.

In this regard, the Board also acknowledges the December 2015 VA Initial PTSD Examination, which does not show a diagnosis of PTSD; however, the Board finds this examination inadequate. The examination states that there is no evidence of mental health related evaluations and treatment, but the claims file contains the May 2015 Landmark Counseling Services records showing a diagnosis of PTSD, and these records were associated with the claims file prior to the Initial PTSD Examination. As such, the examination is inadequate because it is based on an inaccurate premise. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

As noted above, the Veteran has described the firefight he engaged in while stationed in Saudi Arabia and has been awarded the CIB for that service. In this way, the Veteran's lay testimony is sufficient to verify his in-service stressor. As such, there is credible supporting evidence that the claimed in-service stressor occurred.

As to a link between the in-service stressor and PTSD, in an August 2022 Private Medical Examination and Opinion, the doctor first notes that an independent psychological examination was completed, including a clinical interview with the Veteran, and that he reviewed the claims file in its entirety. The doctor then details the Veteran's in-service stressor and states, "It is my expert clinical opinion that [the Veteran] has at least as likely as not (more than 50 percent probability) incurred a service- connected Posttraumatic Stress Disorder (PTSD) and a secondary polysubstance (alcohol, cocaine, and tobacco) use disorder all of which fully conforms to the current DSM-5 diagnostic criteria and continues to persist with increased symptoms and severity uninterrupted through the present time." The doctor describes the Veteran's symptoms and then provides medical research regarding psychiatric disorders and military service, including information concerning substance abuse disorders, in support of his conclusions. The Board finds this opinion to be of great probative value because it is based on an accurate factual premise, with the Veteran's relevant medical history, and it contains a reasoned medical explanation with clear conclusions and supporting data. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise); see also Guerrieri v. Brown, 4 Vet. App. 467 (1993) (the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.). The Board also notes that this medical opinion is uncontradicted.

Accordingly, all elements of service connection for PTSD have been met and service connection is warranted. 38 C.F.R. §§ 3.303, 3.304. In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001).

 

 

MARTIN B. PETERS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Garfield, Jeannine F.

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.