Citation Nr: 0216287 Decision Date: 11/13/02 Archive Date: 11/25/02 DOCKET NO. 99-13 060 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Osborne, Counsel INTRODUCTION The veteran had active military service from April 1973 to March 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1998 and later rating decisions by the RO which denied the claim of service connection for PTSD. In October 2001, the Board remanded the claim of service connection for PTSD for further development. REMAND This claim of service connection for PTSD was previously remanded, in part for compliance with VA's Adjudication Procedure Manual M21-1 (Manual M21-1), Part III, 5.14. This provision outlines specific steps that must be accomplished in order to properly assist veterans who claim service connection for PTSD based on a personal assault. The RO did not comply with the Board's request to consider VA's Adjudication Procedure Manual as it pertained to developing the veteran's claim of service connection for PTSD based on a personal assault. Thus, the case must again be remanded to the RO for such compliance. Stegall v. West, 11 Vet. App. 268 (1998). It is noteworthy to mention that prior to the Board's October 2001 remand, the veteran asserted that he had PTSD due to a physical personal assault in service. Following the Board's remand, psychiatric treatment reports were associated with the claims file. One of the reports received was dated in May 2001. Such report reveals the veteran gave a history of being raped in service. The RO should give the veteran an opportunity to submit evidence corroborating the alleged sexual assault in service. The Board notes that the additional treatment reports received in 2002 indicates that the veteran was evaluated at the PTSD Research Center and that he underwent tests. It is not clear whether complete records from this center have been associated with the claims file. The RO should take appropriate steps to ensure that all of these records have been associated with the veteran's claims file. Furthermore, the veteran claims to be in receipt of Social Security Administration (SSA) disability benefits. In its October 2001 remand, the Board requested that the RO obtain all records from the SSA pertaining to the veteran's disability claim. The RO attempted to obtain the veteran's SSA records. In November 2001, however, the SSA responded that they could not send the medical records requested. They indicated that after an exhaustive and comprehensive search they were unable to locate the veteran's folder. The veteran should be advised that he should submit any records from the SSA that may be in his possession, including medical records and the SSA decision. Any treatment records regarding a psychiatric disorder which are not already on file should be obtained. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). In view of the foregoing, the case is REMANDED to the RO for the following: 1. The RO should contact the veteran and once again give him an opportunity to submit all sources where he received psychiatric treatment since service. Complete clinical records of all such treatment not already on file should be obtained. In this regard, the RO must state for the record that all psychiatric treatment reports from the PTSD Research Center, including all tests and studies, have been associated with the claims file. 2. The RO should contact the veteran in writing for the purpose of advising him of the evidence needed to substantiate his claim for service connection for PTSD based on governing laws and regulations, and VA's Adjudication Procedure Manual M21-1 (Manual M21-1), Part III, 5.14. The RO should also advise the veteran of his right to submit any additional argument and/or evidence in support of his claim of service connection for PTSD. 3. The veteran must also be requested to submit a comprehensive written statement containing as much detail as possible regarding the in-service physical and sexual assaults and any other stressor to which he alleges he was exposed to in service and which led to the onset of PTSD. Specific details of the claimed stressful events during service, such as the dates of all incidents, locations of the incidents, and the full names of those involved should be requested. The veteran must be advised that this information is necessary to obtain supportive evidence of his claimed stressors, and that he must be as specific as possible because without such details, adequate research for verifying information cannot be conducted. He must also be advised to obtain and submit any verifying data from individuals who might have knowledge of the in-service stressors which is claimed to have led to the onset of PTSD, including statements from fellow servicemen or family members, including any current or former spouse. 4. The RO should also ask the veteran to furnish a listing of any alternative sources from which pertinent evidence concerning the alleged service incident could be obtained. If the veteran provides sufficient identifying information in this regard, then an attempt to obtain such evidence should be made by the RO. The RO should follow all applicable procedures in VA's Adjudication Procedure Manual M21-1 (Manual M21-1), Part III, 5.14. Any additional evidence submitted by the veteran or otherwise obtained should be associated with the claims folder. In particular, the veteran should respond to the following with as much specificity as possible: (a) Was any medical care sought from service department or civilian medical personnel immediately following the alleged inservice physical/sexual assaults or in the months following the incidents? If so, the dates of such treatment and the facility should be identified (i.e. name, address). (b) Was the incidents ever reported to civilian or military authorities? If so, give detailed information concerning the place where it was reported and the name(s) of the people who took the report. (c) Were the services of a crisis intervention center ever sought? (d) Were family members, roommates, fellow service members, or clergy told of the claimed inservice sexual/physical assaults. If so, the veteran should be advised to get statements from these individuals and such statements should indicate the date that the veteran shared his claimed service trauma with them. (e) Were there any behavioral changes following the incident, including but not limited to (i) a visit to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; (ii) a sudden request for a change in military occupational specialty or duty assignment; (iii) the occurrence of episodes of depression, panic attacks or anxiety but no identifiable reasons for the episodes; (iv) substance abuse involving alcohol or drugs; (v) increased use of leave without immediate reason; (vi) changes in performance evaluations; (vii) increased or decreased use of prescribed or over-the-counter medications; (viii) disregard for military or civilian authority; (ix) obsessive behavior such as over or under eating; or (x) unexplained economic or social behavior changes? 5. After assuring compliance with the above development, the RO should review the claim of service connection for PTSD. If the claim is denied, the veteran and his representative should be issued a supplemental statement of the case and given an opportunity to respond. Then, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 Appeals for Veterans Claims 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. 2002) (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. N. R. ROBIN Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2001).