Case: 20-6295 Remand For Army Veteran When the Board Made its Own Medical Determination

Case: 20-6295

Facts of Case

The Veteran developed back pain, bilateral lower radiculopathy, and headaches after an in-service motor vehicle accident and subsequent slip and fall during service. He also suffered a post-service fall down a flight of stars with associated back pain.

The Veteran filed a claim for a back disorder, cephalalgia to include headaches, and bilateral radicular pain. However, the Board found that (1) the Veteran’s service treatment records do not reflect “an incident that would result in [symptoms of bilateral sciatic radicular pain]” and (2) “the evidence suggests that the Veteran’s current disability is related to his post-service fall at work.” The Board essentially relied on a post-service notation that the Veteran suffered back pain from a post-service fall down the flight of stairs.

Alex Argued That the Board’s Determination Was an Unsupported Medical Opinion

The Board is prohibited from making unsubstantiated medical judgments. See Colvin v.

Derwinski, 1 Vet. App. 171, 175 (1991). However, the Board is permitted to draw inferences based on an overall medical report so long as the inference does not result in a medical determination. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Under Colvin, when a Board inference results in a medical determination, the basis for that inference must be independent and it must be cited. See Kahana at 428, 435 (2011).

Alex argued that here, the Board provided no independent medical basis for these two findings. The medical note documenting a post-service fall at work, did not review the Veteran’s whole record or make a final determination on causation for the Veteran’s current condition - it was merely a note documenting a fall with back pain at the time. Therefore, the Board’s determination that the Veteran’s current condition was caused by the post-service fall at work was an inference, which resulted in an independent medical determination and was not supported by medical evidence in the record.

Court Sides With the Veteran and Vacates Denial

The Court vacated the Board’s decision and held that remand is warranted for the Board to provide an adequate statement of reasons or bases that is properly supported by independent medical evidence.