Citation NR: 9615641 Decision Date: 06/06/96 Archive Date: 06/18/96 DOCKET NO. 94-04 111 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Milo H. Hawley, Counsel REMAND The veteran had active service from August 1964 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 1991 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. When the veteran filed his claim for service connection for post-traumatic stress disorder in October 1990 he indicated that he had service in the Army from August 1964 to June 1967 and service in the Coast Guard from September 1967 to June 1972. Although the veteran subsequently indicated that his service in the Coast Guard from September 1967 to June 1972 was actually as a civilian merchant marine, the National Personnel Records Center, in January 1991, certified that the veteran had service in the Coast Guard from September 1967 to June 1972 and from June 1972 to March 1978. However, with that certification the National Personnel Records Center, according to a handwritten note, supplied records belonging to two different veterans. Therefore, while it appears that the veteran's service from September 1967 to June 1972 was as a civilian merchant marine, not qualifying for active service for purposes of VA benefits, it is unclear whether the veteran served from 1972 to 1978, and if he did what type of service he had. A response from the Coast Guard, received in February 1992, reflects that it does not maintain medical records for merchant mariners. It refers to an enclosed list of addresses of agencies which could be of further assistance in obtaining the veteran's medical records while serving as a merchant marine, but the list of addresses does not appear to be in the file. The report of a November 1990 VA psychiatric examination states the diagnosis of generalized anxiety disorder. A VA hospital discharge summary, relating to a period of hospitalization in November and December 1990, states a psychiatric diagnosis of adjustment disorder with mixed features. A VA hospital discharge summary, relating to a period of hospitalization in March and April 1991, and VA outpatient treatment records, dated from 1993 to 1995, include the diagnosis of PTSD. When it is concluded that a veteran was engaged in combat with the enemy and his reported stressors are related to such combat, his testimony as to those stressors will be accepted as conclusive without further development to corroborate said testimony being required, assuming the testimony is found to be credible and consistent with the circumstances of the veteran's service. Zarycki v. Brown, 6 Vet.App. 91-98 (1993). Where "VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain service records which corroborate the veteran's testimony as to the occurrence of the claimed stressor.” West v. Brown, 7 Vet.App. 70, 76 (1994). In West, at 77, 78, the Court noted that the requested psychiatric examinations which had found PTSD were inadequate in that they considered evidence supplied by the veteran which had been determined to be inconsistent with the record. The Court directed that a psychiatric examination be conducted on the complete and accurate record. It is for the psychiatric examiners to determine whether they recalled events, as they actually happened, constituted stressors sufficient to support a diagnosis of PTSD. The report of the November 1990 VA examination reflects that the veteran was seen without the claims folder or other records. In light of the above, the Board believes that additional development is required prior to further appellate review. Accordingly, the case is REMANDED to the RO for the following: 1. The RO should contact the veteran and request that he identify names, addresses, and approximate dates of treatment for all health care providers from whom he has received treatment for PTSD at any time since service. With any necessary authorization from the veteran, the RO should attempt to obtain those records identified by the veteran which are not currently of record. 2. The RO should contact the veteran and ask him to clarify if he had service in the Coast Guard from June 1972 to March 1978, and if so, whether he was a civilian merchant marine at that time or if he was on active duty with the Coast Guard. If his response is that he was on active duty in the Coast Guard during that time frame, appropriate verification from the Coast Guard should be obtained. If the veteran indicates that he was on active duty with the Coast Guard, all Coast Guard service personnel records should be requested. 3. The RO should ascertain what list of agencies the February 1992 response from the Coast Guard referred to and attempt to obtain any of the veteran's medical records as a civilian merchant marine from the appropriate agency. 4. The RO should request that the veteran provide more detailed facts, if available, about the stressful events he claims to have experienced during service. The RO should also request that the veteran provide dates and places, as well as his unit assignment, at the time of each claimed stressor. If any of his fellow servicemen, were killed or wounded in action, the veteran should provide the name and approximate date of death or injury for each person. To the extent that he provides time frames within which individuals were killed or injured, including the lieutenant alleged to have been injured by the grenade, the RO should obtain the morning reports for the veteran's unit for the time frames specified. The RO should also obtain the histories of the units to which the veteran was assigned while in Vietnam, for the period he was in Vietnam. The information provided by the veteran concerning the specific circumstances of the claimed stressors, a copy of the service records documenting the veteran's unit assignments, morning reports and histories of the units to which the veteran was assigned while in Vietnam for the period he was in Vietnam should again be forwarded to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, for verification of the stressors claimed by the veteran. 5. The RO must then make a specific determination, based upon the complete record, with respect to whether the veteran was engaged in combat with the enemy at any time and whether any of his reported stressors occurred during such activity so that further corroboration is not required. If the RO determines that the record establishes the occurrence of any other claimed stressful event or that certain stressors must be presumed, the RO must specify what additional stressor or stressors it has determined are established by the record, or must be presumed. In reaching this determination, the RO should address any credibility questions raised by the record. 6. After the RO determines whether the record establishes the existence and nature of any stressor or stressors, the RO should schedule the veteran for an examination by a board of two VA psychiatrists, board certified, if available, experienced in evaluating PTSD to determine the diagnosis of all psychiatric disorders that are present. The RO must furnish the examiners a complete and accurate account of the stressor or stressors that it has determined are established by the record and the examiners must be instructed that only those events as reported in the record may be considered for the purpose of determining whether inservice stressors were severe enough to have caused the current psychiatric symptoms and whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied by the inservice stressors. It is imperative that the claims file be made available to the examiners for review in connection with the examination. The examination report should reflect review of pertinent material in the claims file, including the service and historical records which describe the details of the stressful events found to have been established by the RO. Any opinion expressed should be accompanied by a detailed rationale. All necessary tests and studies should be conducted. 7. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for PTSD. If the benefits sought on appeal are not granted to the veteran's satisfaction or if a timely notice of disagreement is received with respect to any other matter, both the veteran and his representative should be provided a supplemental statement of the case on all issues in appellate status and should be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to the ultimate outcome warranted. No action is required of the veteran until he is otherwise notified. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1995), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1995). - 2 -