Citation Nr: 0318926 Decision Date: 08/04/03 Archive Date: 08/13/03 DOCKET NO. 99-08 603 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for psoriasis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L.J. Bakke, Counsel INTRODUCTION The veteran served on active duty from March 1951 to July 1953. Service personnel records further show that she served in the Army Reserve from October 1983 to July 1988. This appeal arises before the Board of Veterans' Appeals (Board) from a rating decision rendered in September 1998 by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. In February 2002, the case was remanded to the RO for additional development. The case has been returned to the Board for appellate consideration. In December 2000, the veteran testified at a video conference hearing before a member of the Board (now Veterans Law Judge) appearing at the RO, who will render the final determination in this claim and was designated by the Chairman of the Board to conduct the hearing. 38 U.S.C.A. § 7102(b) (West 2002). A copy of the hearing transcript issued following the hearing is of record. REMAND This case was previously before the Board in February 2001, when the Board remanded it for further development including development in accordance with the Veterans Claims Assistance Act of 2000 (VCAA), now codified at 38 U.S.C.A. § 5102, 5103, 5103A, 5107 (West 2002). In addition, the Board requested that the RO procure records concerning the veteran from the Social Security Administration (SSA); again attempt to obtain the veteran's service medical and personnel records, which may have been destroyed by the fire at the National Personnel Records Center (NPRC) in 1973, including using alternative means to reconstruct the records if they cannot be obtained; and develop the case in accordance with VA Adjudication Procedure Manual M21-1 (Manual M21-1), Part III, para. 5.14(c) (Feb. 20, 1996), in accordance with Patton v. West, 12 Vet. App. 272, 280 (1999). The Board has reviewed the record and finds, regrettably, it is necessary to remand this claim for compliance with the February 2001 Remand. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Court or Board confers on the claimant, as a matter of law, the right to compliance with the remand orders). While the RO attempted to comply with the terms of the Remand, the Board notes several deficiencies. First, although the RO made a second request for the veteran's records from NPRC, which resulted in procuring records from the veteran's reserve service, no further records were obtained for her first period of active service. There is no indication in the claims file that the RO attempted alternative means of reconstructing the missing records. This must be accomplished. Second, while the RO gave the veteran an opportunity to describe the stressors that she feels precipitated her PTSD, the record does not document that the RO developed the averred sexual assault under the steps proscribed by Manual M21-1, Part III, para. 5.14(c). This, also, must be done. Third, the RO obtained records from SSA concerning the veteran. However, in these records are records concerning another individual of a different name. The Board finds that clarification must be made to determine that the RO has all records from SSA concerning the veteran. To ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should ensure that it has records from all VA and non-VA health care providers who treated her for her PTSD and psoriasis. Where necessary, the RO should procure duly executed authorization for the release of private medical records. In particular, the RO should obtain copies of treatment accorded the veteran for her PTSD from Nabil Jouni, M.D. and for her psoriasis from Lucius Blanchard, M.D., both of Las Vegas, Nevada, and for her PTSD and psoriasis from the VA Medical Center (VAMC) in Las Vegas, Nevada from 2001 to the present. The RO should also procure copies of records of treatment accorded the veteran at the base hospital at Fort George G. Meade Hospital at Fort Meade, Maryland from 1953 to approximately 1960. The RO should request any and all mental hygiene records, including any and all individual and group therapy records, as well as pre-natal, maternity, and other treatment records. The RO should request searches under the veteran's social security number, her service number, and indicate all possible names the veteran may have used. The RO should also request that the search be made for her as a service- member as well as a civilian. 2. The RO should clarify the status of the veteran's file with SSA and verify that it has obtained all documents concerning the veteran's disability claim with SSA in existence that are relevant to her claim for service connection for PTSD and psoriasis. 3. The RO should further request that the veteran provide specific information about her treatment in hospitals during her active service. She should be asked to provide the names of the medical facilities at which she was treated, the dates of treatment, and any other pertinent information. Remind the veteran that she may solicit statements from her brothers and other potential witnesses who may remember the names and precise locations of these hospitals. 4. The veteran's response notwithstanding, the RO should request SGO records for the veteran from 1951 to 1953 and take any additional action necessary to determine the veteran's units of assignment and to verify her hospitalizations: ? During basic training at F.E. Warren Air Force Base in Wyoming ? At Lackland Air Force Base ? During her overseas assignment in Tokyo in 1953 ? In Philadelphia in 1953 ? At Mitchel Air Force Base in New York in 1953 ? At Fort George G. Meade Hospital at Fort Meade, Maryland, just prior to and after her discharge in 1953. The RO is reminded to search under both the veteran's social security and service numbers, and to search under all names that the veteran has used. 5. The RO should then make specific attempts to obtain any additional service medical records for the veteran's period of active service from 1951 to 1953. Her report of medical examination at discharge in July 1953, which is the only record so far obtained, indicates that she attempted suicide and was hospitalized for five months for schizophrenic reaction. Please request any and all mental hygiene records from the hospitals identified above, as well as any hospital that the veteran may identify. The RO is reminded to search under both the veteran's social security and service numbers, and to search under all names that the veteran has used. 6. The RO should also make specific attempts to obtain the veteran's service personnel records ("201 file") for her period of active service from 1951 to 1953. The RO is reminded to search under both the veteran's social security and service numbers, and to search under all names that the veteran has used. 7. If the service medical or personnel records are unavailable, the RO should use alternative sources to obtain such records, using the information of record and any additional information the veteran may provide. Alternative sources should include, but not be limited to, methods of reconstruction of service records used in fire-related cases and reconstruction from unit morning reports and unit histories. If necessary, the RO should request that the veteran or her representative provide further information. The RO should consider special follow-up by its military records specialist and/or referral of the case for a formal finding on the unavailability of the service personnel records. See VBA's ADJUDICATION PROCEDURE MANUAL, M21-1 Part III, chapter 4, paras. 4.28 and 4.29. 8. The RO should afford the veteran an opportunity to submit statements from individuals who may have knowledge of the events that transpired during her period of active service, such as fellow-service members; or who can attest to changes in her behavior or the reasons for her divorce so soon after her discharge, such as her brothers and other family members. 9. Following this development, the RO should then attempt to verify the veteran's averred stressor under the specialized development procedures proscribed under M21-1, Part III, 5.14(c)(5), involving stressors that are the result of personal assault. The RO is reminded to search under both the veteran's social security and service numbers, and to search under all names that the veteran has used. 10. The RO should ensure compliance with the duty to assist, documentation and notification requirements set forth by the VCAA, specifically including all provisions under 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2002); 66 Fed. Reg. 45,620 (Aug. 29, 2001) (codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a)). The claims file must include documentation that the RO has complied with the VA's redefined duties to notify and assist a claimant as set forth in the VCAA and as specifically affecting the issue on the title page of this remand. 11. When the above development has been completed, the RO should make arrangements to afford the veteran the appropriate VA examination to determine the nature, extent, and etiology of any skin disorder, to include psoriasis; and a VA examination by a Board of examiners to include at least one psychiatrist and one psychologist to determine the nature, extent, and etiology of any neuropsychiatric disorder, to include PTSD. All indicated tests and studies should be performed. If other examinations by specialists are indicated, they should be conducted. Send the claims folder to the examiners for review. The examiners should address the following matters: ? Summarize the medical history, including the onset and course, of the veteran's service skin disorder and neuropsychiatric disabilities, to include psoriasis and PTSD. ? Describe any current symptoms and manifestations attributed to her skin disorder and her neuropsychiatric disability, to include psoriasis and PTSD. ? Complete any diagnostic and clinical tests required and provide diagnoses for any and all symptoms of skin disorder and neuropsychiatric disabilities identified. ? Provide an opinion as to the date of onset and etiology for any currently manifested skin disorder and neuropsychiatric disability. In making this opinion concerning the claimed psoriasis, the examiner is requested to offer an opinion as to whether it is as likely as not that any manifested skin disorder, to include psoriasis, is the result of her active service. Concerning the claimed neuropsychiatric disability, to include PTSD, the examiners are referred to the following: 1. Report of medical examination dated in July 1953, reflecting that the veteran had been hospitalized for five months prior to discharge for a suicide attempt and schizophrenic reaction. 2. The VA examination conducted in April 1999, by Rena M. Nora, M.D., Chief, Psychiatry Service, finding the veteran manifested "features suggesting Posttraumatic Stress Disorder" absent a verifiable stressor. The examiner diagnosed Major Depression with onset during active service. 3. The November 2000 addendum to the above examination, which diagnosed schizoaffective disorder and PTSD secondary to personal assault (stressor which necessitated first psychiatric hospitalization in the military in 1951 (sic) to be verified). 4. VA examination conducted in November 2002 by Joyce M. Oates, M.D., Board Certified Psychiatrist, finding the veteran does not have PTSD nor does she have a history that would "bring[] such a diagnosis into question." The examiner instead diagnosed situational dysthymia and borderline personality disorder. 12. After receipt of any and all newly acquired evidence, the RO should again review the veteran's claims for PTSD and psoriasis. If the decision remains in any way adverse to the veteran, she and her representative should be furnished with a supplemental statement of the case, and with a reasonable period of time within which to respond. The case should thereafter be returned to the Board for further review, as appropriate. The veteran need take no action until she is so informed. The Board intimates no opinion as to the ultimate outcome of this case. The veteran is advised that failure to appear for a scheduled VA examination without good cause could result in the denial of her claims. 38 C.F.R. § 3.655 (2002). 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 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. _________________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 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) (2002).