Citation NR: 9622411 Decision Date: 08/14/96 Archive Date: 08/16/96 DOCKET NO. 94-23 692 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Whether new and material evidence has been submitted to reopen a claim for service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Raymond F. Ferner, Counsel INTRODUCTION This matter comes before the Board of Veterans’ Appeals (BVA or Board) on appeal from a December 1993 rating decision of the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan (RO), which denied the benefits sought on appeal. The veteran, who had active service from September 1970 to June 1972, appealed that decision to the BVA, and the case was referred to the Board for appellate review. REMAND A preliminary review of the record discloses several areas which would benefit from evidentiary development and aid the Board in the disposition of the issue on appeal. In April 1996, the veteran submitted a statement in which he indicated that St. Louis, presumably the National Personnel Records Center (NPRC), had advised him that he was a recipient of the Combat Action Ribbon. Accompanying that statement was an NAVMC 118(11) (Administrative Remarks), apparently from the veteran’s personnel records, which contained an entry of “Combat Service Code 9.” While the RO indicated in a supplemental statement of the case that the veteran’s service personnel records did not confirm the award of a Combat Action Ribbon, it is unclear what the significance is of the “Combat Service Code 9.” It is also unclear from the record when the veteran was actually in Vietnam. The veteran has indicated varying periods of time, but service personnel records do not reflect the veteran’s presence in Vietnam. Specifically, a NAVMC 118(17) (Sea and Air Travel-Embarkation Slips) does not show the veteran’s arrival in or departure from Vietnam, and the NAVMC 118(9) (Combat History-Expeditions-Awards Record) reflects the presence of the veteran in the contingent waters of Vietnam for four days in May 1971 and for three days in June 1971. The Board believes that further clarification with respect to the veteran’s time in Vietnam and the significance of the “Combat Service Code 9” would be helpful. Further review discloses that a March 1981 statement from Erol Ucer, M.D., relates that the veteran was initially seen by him in September 1975, at which time the veteran was diagnosed as having paranoid schizophrenia. That statement indicates that the veteran was referred by his family physician and that “[p]roblems became apparent after the patient’s graduation from high school.” The Board believes that an attempt should be made to identify the veteran’s family physician and obtain records from that physician in order to more clearly delineate the date of onset of the veteran’s schizophrenia. The veteran also testified that he witnessed the wounding or death of a service comrade when he stepped on a land mine. (Transcript at 4-5, 14.) The veteran identified the individual as “Frog” but recalled the name of Philip Frazier or Philip Freeze at the hearing. The Board believes that an attempt should be made to verify the circumstances surrounding the wounding or death of the individual referred to by the veteran. Lastly, the Board believes that, should information be obtained which satisfies the requirements of 38 C.F.R. § 3.304(f) (1995), the veteran should be afforded a VA examination to reconcile the various diagnoses of record and determine whether the veteran satisfies the diagnostic criteria for a diagnosis of PTSD. Therefore, in order to give the veteran every consideration with respect to the present appeal, it is the Board's opinion further development of the case is necessary. Accordingly, this case is REMANDED for the following actions: 1. The RO should attempt to ascertain the identity of the physician who referred the veteran to Erol Ucer, M.D., in 1975, and, after obtaining the necessary authorization, obtain all medical records pertaining to the veteran from that physician. This information should be sought from the veteran, and it necessary, from Dr. Ucer. 2. The RO should obtain verification of the dates the veteran was in Vietnam, as opposed to in the contingent waters, and clarification of the “Combat Service Code 9” on the NAVMC 118(11) submitted by the veteran. The RO should also request verification, of the circumstances surrounding the wounding or death of a service comrade Philip Frazier or Freeze during the time the veteran was in Vietnam. 3. If, and only if, information is obtained which satisfies the requirements of 38 C.F.R. § 3.304(f) (1995), the veteran should be afforded a psychiatric examination to ascertain the nature, severity and etiology of the psychiatric disorders which are present. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The primary purpose of the examination is to ascertain whether the veteran satisfies the diagnostic criteria for a diagnosis of PTSD. The examiner is specifically requested to review all pertinent medical records and attempt to reconcile the various diagnoses of record, but should specify whether the veteran has PTSD. Since it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1 (1995), copies of all pertinent medical records in the veteran’s claims file or, in the alternative, the claims file, must be made available to the examiner for review. When the development requested has been completed, the case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the veteran and his representative should be furnished a supplemental statement of the case, and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The veteran is free to submit any additional evidence he desires to have considered in connection with his current appeal. No action is required of the veteran until he is notified. JACQUELINE E. MONROE 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), 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 -