History of the case
The Veteran was awarded service connection for migraine headaches in September 2003. One year later, she requested an increased evaluation for migraine headaches. She then filed a claim for service connection for a psychiatric disorder. An August 2007 psychologist opined that the Veteran’s psychological stress was negatively affecting her physical health. In February 2009, the Veteran clarified that she was claiming service connection for depression secondary to migraine headaches. The Veteran reported that her migraines contributed significantly to her depression. Specifically, they required her to frequently lie down in a dark room. A psychiatric examiner opined that the major depressive disorder appeared as likely as not to be due to migraines.
In April 2009 the Regional Office granted service connection for major depressive disorder as secondary to migraines. This grant was effective as of February 13, 2009. The Veteran successfully appealed this effective date to the Court. The Board thus remanded the claim for a new medical opinion. The September 2015 examiner rendered a negative nexus opinion, finding that there was no documentation that the migraines negatively impacted the Veteran’s mood.
Board denies earlier effective date Veteran’s major depressive disorder
In the decision on appeal, the Board denied an earlier effective date prior to February 13, 2009 for service connection for major depressive disorder. The Board placed significant value on the the September 2015 medical opinion as it confirmed that there was no evidence prior to February 2009 reflecting a psychiatric impact of service-connected migraine headaches.
Court agrees that medical opinion was inadequate to deny service connection
The Veteran appealed this denial to the Court. She argued, and the Court agreed, that the Board failed to ensure that the VA fulfilled the duty to assist. Specifically, it failed to obtain an adequate medical opinion addressing whether it was factually ascertainable prior to February 13, 2009, that the Veteran’s psychiatric condition was caused or aggravated by her service-connected migraine headaches.
The Court found that the September 2015 examiner’s rationale was inadequate because she ignored potentially favorable evidence of record. Although the examiner indicated that she reviewed all the relevant evidence of record, her rationale focused on the lack of a definitive medical relationship as noted in VA mental health treatment records, and she failed to discuss potentially favorable evidence of record suggesting a relationship between migraines and depression prior to February 2009. The Court concluded that the Board erred in relying on the September 2015 opinion, and remanded the case for a new medical opinion.