Citation NR: 9732280 Decision Date: 09/23/97 Archive Date: 09/29/97 DOCKET NO. 95-42 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for post traumatic stress disorder (PTSD). 2. Entitlement to service connection for a skin disorder of the feet. REPRESENTATION Appellant represented by: Georgia Department of Veterans Service WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. Strommen, Associate Counsel INTRODUCTION The veteran served on active duty from October 1967 to November 1970. This case comes before the Board of Veterans’ Appeals (Board) from a rating decision rendered in March 1993, in which the Atlanta, Georgia, Regional Office (RO) of the Department of Veterans Affairs (VA) denied the veteran’s claims of entitlement to service connection for PTSD and a skin disorder of the feet. The veteran subsequently perfected an appeal of that decision. A hearing on this claim was held in Atlanta, Georgia, on June 4, 1997, before Jeff Martin, who is a member of the Board and was designated by the chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). The Board notes that at his June 1997 hearing the veteran raised a claim of entitlement to a compensable rating for his service-connected hepatitis. This issue has not been developed by the RO and is referred to the RO for appropriate disposition. Additionally, the Board notes that the record contains some confusion as to whether the veteran’s claim of entitlement to service connection for a skin disorder of the feet is a direct service connection claim or connected with a claim of entitlement to service connection due to agent orange exposure. After a review of the record, the Board finds that the veteran has submitted two separate claims relating to a skin disorder, and has only perfected an appeal of his direct service connection claim. Accordingly, the issues before the Board are properly identified on the title page. REMAND After a review of the record, it is the opinion of the Board that additional development of the evidence should be accomplished prior to further consideration of the veteran’s claims. Service connection for PTSD may be granted where the record shows a current, clear medical diagnosis of PTSD, credible supporting evidence that the claimed in service stressor actually occurred, and medical evidence of a causal nexus between current symptomatology and the specific in service stressor. Cohen v. Brown, No. 94-661 (U.S. Vet. App. March 7, 1997). Initially, addressing the stressor evidence, the veteran has asserted in statements and testimony that despite his military occupational specialty as a light truck driver he participated in reconnaissance and search and destroy missions with the Bravo Company, and engaged in several firefights during his first tour of duty in Vietnam. The RO has maintained that he has no combat medals, that he did not serve in the infantry, and, accordingly, that he has no evidence of combat service. Although it is acknowledged that Captain Robert Fox, identified by the veteran as a friend killed while he was overseas, did serve in his unit and was killed during the veteran’s first tour. However, a review of the veteran’s service personnel records, and the records submitted by the Environmental Support Group (ESG) for the period from May to July 1968, show that from May 1968 to September 1968 the veteran was assigned to the headquarters company of the Second Battalion (airborne) of the 503rd Infantry in the 173 Airborne Brigade. Additionally, although the ESG records primarily involve information relating to the North Vietnamese Army’s location and casualties, they do indicate that throughout the period addressed the 173 Brigade in general, and the 2nd Battalion of the 503 Infantry specifically, did engage in combat operations with the enemy. These combat operations included reconnaissance and search and destroy missions which resulted in some American casualties. Given the evidence indicating that the veteran was assigned to an infantry division which engaged in combat operations, the Board finds that additional attempts should be made to confirm the veteran’s alleged stressors. Specifically, the RO should again contact ESG and request that they provide information as to names of persons assigned to the 173 Airborne Brigade, Second Battalion, 503 Infantry, for the period from April 1968 to February 1969, particularly a breakdown of what persons were attached to the various companies within this division. Additionally, the RO should request that ESG provide information regarding the specific activities of these companies, specifically Bravo Company and HHQ Company, during this time, as opposed to just the Learned Lessons notations previously submitted. Finally, at his June 1997 hearing, the veteran identified a Tyler and Vandemon or Van Demon as two other friends killed during his first tour, although he asserts that neither were in Bravo company. Therefore, the RO should also request that ESG provide information as to the casualties in the 173 Airborne Brigade during the period from April 1968 to February 1969, to determine if any soldiers with the surname of Tyler or Vandemon or Van Demon were killed during this period. Turning to the evidence of a clear diagnosis and identification of a relationship between the veteran’s alleged stressors and his PTSD diagnosis, a review of the record reveals that although the veteran has several VA hospitalization reports and two VA examinations which diagnose him with PTSD, none of these records specifically identify the stressors relied upon to formulate their diagnoses. While these reports mention the veteran’s flashbacks and intrusive thoughts regarding dead bodies and combat missions, they fail to relate these as specific stressors. Additionally, the Board notes that attempts by the RO to clarify the diagnosis of Dr. K. Sujatha Reddy of the VA medical center (VAMC) in Dublin, Georgia, were unsuccessful. Accordingly, the Board remands this claim for an examination by two VA psychiatrists, who have not previously examined the veteran. If the examiners determine that the veteran is suffering from PTSD, they should specifically identify the stressors relied upon to reach that diagnosis. Furthermore, the Board notes that the veteran has asserted that he was treated for PTSD at the VAMC in Tuskegee, Alabama, in 1995 and 1996, and that he has been treated for PTSD by a private physician, Dr. Coates, in recent years; however, these treatment records are not in the claims file. Additionally, the veteran testified at his June 1997 hearing that he receives Social Security Administration (SSA) disability benefits for his psychiatric disorder. These records are also not in the claims file. The Board finds that such records may be probative to the veteran’s pending claim, and accordingly, the treatment reports and SSA records should be requested and associated with the veteran’s claims folder for RO review. See Murincsak v. Derwinski, 2 Vet.App. 363, 369-72 (1992); 38 U.S.C.A. § 5103(a) (1996). With regard to the veteran’s claim of entitlement to service connection for a skin disorder of the feet, the Board notes that while there are some treatment records in the file showing treatment in February 1993, January 1994, and June 1994 for chronic tinea pedis, that a VA foot examination was scheduled but never held. Furthermore, service medical records, to the extent that they are legible due to water damage, show treatment for a skin rash of the feet in September 1968, October 1968, July 1969, November 1969, June 1970 and July 1970, although the discharge examination shows his feet and skin to be normal. Given that this evidence, despite the absence of a skin disorder at discharge, indicates that the veteran may have a chronic skin disorder on his feet which began in service, the Board finds that this claim should be remanded for an examination of the veteran’s feet, and a determination as to the etiology and date of onset of his pedal skin disorder. Additionally, upon remand the veteran should be given the opportunity to add any recent lay or medical evidence to the record. See 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1996); Quarles v. Derwinski, 3 Vet.App. 129 (1992). While the Board regrets the delay involved in remanding this case, under the circumstances discussed above, it is felt that proceeding with a decision on the merits at this time would not withstand scrutiny by the Court. For that reason, to ensure due process, and to ensure that the VA has met its duty to assist the veteran in developing the facts pertinent to his appeal, the case is REMANDED to the RO for the following development: 1. The RO should notify the veteran that he may submit additional evidence and argument in support of his claims. Additionally, the RO should ask the veteran to identify the dates of stressor events, and the names of places and persons present during his stressor events; he should also be asked to describe in detail the stressor events themselves, such as the sniper attacks, the reconnaissance and search and destroy missions, the finding or observing dead soldiers, and the mortar attacks. 2. The RO should also request that the veteran furnish the names and addresses of all health care providers who treated him since service for his PTSD; specifically, the name, address, and treatment dates for Dr. Coates. Following receipt of such information, and duly executed authorization for the release of private medical records, the RO should request that all identified health care providers, whose treatment records are not already of record, furnish legible copies of all medical records compiled in conjunction with treatment accorded the veteran for PTSD. 3. The RO should also take all appropriate steps to obtain all records compiled in conjunction with the Social Security Administration’s award of disability benefits to the appellant, to include, but not limited to, the award decision and all medical records considered pursuant thereto. 4. The RO should also attempt to secure copies of all VA outpatient treatment records and hospitalization reports pertaining to the veteran from the VA medical facility in Tuskegee, Alabama, from January 1995. 5. Upon receipt of the veteran’s stressor information, or in its absence if the veteran fails to respond, the RO should contact the United States Army Environmental Support Group (ESG) and request that ESG corroborate the veteran’s stressors to the best of its ability. Specifically, the RO should request that ESG provide information regarding the specific activities and names of the soldiers in the Bravo and HHQ companies of the Second Battalion (Airborne), 503 Infantry, 173 Airborne Brigade for the period from April 1968 to February 1969. Additionally, the RO should request that ESG provide information as to the casualties in the 173 Airborne Brigade during the period from April 1968 to February 1969, to determine if any soldiers with the surname of Tyler or Vandemon or Van Demon were killed during this period. If the ESG requires additional information from the veteran in order to complete its investigation, the RO should inform the veteran of the information needed, and attempt to obtain this information from him and forward it to the ESG. 6. After completion of the above, and association of any accumulated evidence with the claims file, the RO should accord the veteran a psychiatric examination before a board of two VA psychiatrists. The claims file, with the newly obtained evidence, must be forwarded to the board of two psychiatrists and reviewed by them prior to the examination. Neither of the two psychiatrists should have previously examined the veteran. The veteran should be informed of the consequences of failing to report for this examination. If the veteran is diagnosed with PTSD, the examiners should be requested to explain the sufficiency of each specific stressor relied upon for the diagnosis, the basis for the conclusion that the veteran’s symptomatology was adequate to support a diagnosis of PTSD, and whether there is a causal nexus between the veteran’s specific in service stressor(s) and his current symptomatology. 7. The RO should also accord the veteran an examination to ascertain the date of onset, etiology, and current manifestation of his skin disorder of the feet. The RO should inform the veteran of the consequences of failing to report for the examination when he is notified of its time and location. It is important that the examiner be afforded the opportunity to review the veteran’s claims folder prior to the examination. The examination should include all necessary tests and studies. The examiner should be specifically requested to provide an opinion as to the approximate date of onset and etiology of the veteran’s disability, to the extent possible. If the condition is not present at the time of the examinaion, the examiner should render an opinion based on the information in the claims file and any additional information provided at the examination. All findings, and the reasons and bases therefor, should be set forth in a clear, logical and legible manner on the examination report. 8. After the development requested above has been completed to the extent possible, the RO should again review the record and consider all the additional evidence. If any benefit sought, for which an appeal has been perfected, remains denied, the veteran and his representative should be furnished a supplemental statement of the case, and given the opportunity to respond thereto with additional argument and/or evidence. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action until notified. 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. JEFF MARTIN 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 -