Citation NR: 9730628 Decision Date: 09/05/97 Archive Date: 09/11/97 DOCKET NO. 96-06 924 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia THE ISSUE Entitlement to service connection for a seizure disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Schlosser, Associate Counsel INTRODUCTION The veteran had active military service from November 1983 to May 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 1995 rating decision in which the RO denied service connection for a seizure disorder. The veteran appealed. He was afforded a hearing at the RO in July 1996. His claim was denied by the hearing officer in a December 1996 decision as reflected in a December 1996 Supplemental Statement of the Case (SSOC). REMAND The veteran and his representative contend, in essence, that he should be service connected for a seizure disorder. Specifically, the veteran maintains that repeated blows to the head in service caused his seizure disorder. Following a complete review of the claims folder, the Board finds that further development is required. The service medical records show that the veteran was seen in December 1984 after he was allegedly hit in the forehead by a Japanese civilian. The diagnosis was forehead hematoma. He was hospitalized from January 5 to January 8, 1985, at the Yokosuka Naval Hospital in Japan with a diagnosis of syncope of unknown etiology. The clinical records report a history of syncopal episodes 1 1/2 years prior to the current episode. The veteran indicated that he felt lightheaded and unsteady with blurred vision. He complained of vague chest discomfort. He reported a history of being hit in the head by a brick when he was a child which required sutures. The veteran also noted a frontal head injury 3-4 years earlier and a recent history of being hit in the head 3 weeks prior to admission. Examination was within normal limits. An electrocardiogram (EKG) was normal. Evaluation via telemetry over a two day period was negative. X-rays of the skull were reported to be within normal limits. The veteran was discharged to return to full duty. In February 1985, the veteran was seen for dizzy spells. The assessment was vasovagal lightheadedness. In April 1985, the veteran reported hitting his head on a low overhead while boarding the ship. He denied loss of consciousness. The veteran was noted to have incoherent speech and an “obvious odor” of alcohol on his breath. There was no sign of neurologic damage. Diagnostic impression was superficial abrasion of the forehead. He was prescribed Antabuse on April 30, 1985, based on identification of an “alcohol problem” with increasing blackouts. After he complained of dizziness and drowsiness, Antabuse was discontinued. On separation examination in May 1986, there were no pertinent defects noted. On VA examination in June 1995, the veteran was noted to have a history of a seizure disorder diagnosed in 1985. He was noted to take Dilantin and reported a few seizures per month. The veteran reported that his seizures are manifested as blackout spells with jerking all over. He has headaches after a seizure. Neurological examination revealed no right/left disorientation. The veteran had no dysarthria, no dysnomia and was able to perform cross midline. The diagnosis was seizure disorder with no focal neurological deficit. At the July 1996 RO hearing, the veteran said that he had suffered several head injuries in service which initiated his seizures. He reported that he was hospitalized for three days in Japan and observed for seizures at the Yokosuka Naval Hospital. He said that he was advised by military personnel that he had a seizure disorder and was prescribed Dilantin in service. The veteran’s representative noted at the hearing that the report of this hospitalization had not been associated with the claims folder. A review of the service medical records shows that a narrative summary from the veteran’s 3 day hospitalization at the Yokosuka Naval Hospital has been obtained and associated with the claims folder. The veteran also testified that he had undergone a brain scan at the Palmyra Park Hospital which showed 15 percent brain damage. He indicated that he would provide a release so that these records could be obtained. Following the hearing, the RO sent the veteran an Authorization for Release of Information (VA Form 21-4142) for the purpose of obtaining records from the Palmyra Park Hospital. The veteran did not return the form authorizing a release of his medical records at that facility. We do have private clinical records showing treatment for a seizure disorder in 1992, 1995 and 1996. The veteran also testified at the RO hearing that he receives Social Security Disability benefits. The decision awarding such benefits and the records underlying the award have not been associated with the claims folder. The Court has held that in such instances, and with regard to the issues before the Board on appeal, the medical records underlying the award of Social Security Disability benefits must be obtained and reviewed by VA. Massors v. Derwinski, 2 Vet.App. 181 (1992); Murincsak v. Derwinski, 2 Vet.App. 363 (1992). The case is REMANDED to the RO for the following action: 1. The RO should send the veteran an Authorization for Release of Information (VA Form 41-42) for the Palmyra Park Hospital in Albany, Georgia. The veteran should be advised that he must return the release so that his records can be obtained from this facility. Based on his response, the RO should obtain a complete copy of all treatment records referable to the veteran’s seizure disorder from this facility and associate them with the claims folder. 2. The RO should also ask the veteran whether he has received any additional treatment for his seizure disorder since February 1996, the date of the most recent treatment records associated with the claims folder. Based on his response, the RO should obtain a copy of all treatment records referable to the veteran’s seizure disorder from the identified source(s) since February 1996, and associate them with the claims folder. 3. The RO should obtain a complete copy of the veteran’s file with the Social Security Administration, including a copy the decision awarding benefits and a copy of all medical records associated with the veteran’s application which supported the award of such benefits. 4. Following the receipt of the aforementioned records, the RO should schedule the veteran for a complete neurological evaluation, to ascertain the nature and etiology of any currently demonstrated seizure disorder. All indicated testing in this regard should be accomplished. The claims folder MUST be made available to the examiner for review before and during the examination and the examiner should indicate in his report that the claims folder was reviewed. Following examination of the veteran, it is requested that the examiner express an opinion as to the following: (1) whether it is at least as likely as not that any currently demonstrated seizure disorder was present during service or within one year of discharge from service; (2) whether it is at least as likely as not that any currently demonstrated seizure disorder is the result of head trauma suffered in service, or whether it is due to other causes. A complete rationale for the examiner’s opinion should be provided. 5. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the aforementioned development action has been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. The RO should then review the record and the claim should be readjudicated. If the determination remains adverse to the veteran, both the appellant and his representative should be provided a Supplemental Statement of the Case. The veteran and his representative should be given the opportunity to respond within the applicable time. Thereafter, the case should be returned to the Board, if in order. The appellant need take no action unless otherwise notified. The purpose of this remand is to procure clarifying data. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. BRUCE E. HYMAN Member, Board of Veterans' Appeals 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) (1996). - 2 -