Citation Nr: 0814968 Decision Date: 05/06/08 Archive Date: 05/12/08 DOCKET NO. 97-06 642A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Nancy Rippel, Counsel INTRODUCTION The veteran had active military service from August 1990 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) from a Memorandum Decision of the United States Court of Appeals for Veterans Claims (Court) dated in November 2007 that vacated and remanded a July 2005 Board decision that denied service connection for PTSD. This case originally came to the Board from a May 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction over the veteran's claims folder was transferred to the Wilmington, Delaware RO in August 2001. The veteran testified before a hearing officer at the RO in March 1996. A transcript of the veteran's hearing has been associated with the record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The VCAA duty to assist also requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim and in claims for disability compensation requires that VA provide medical examinations or obtain medical opinions when necessary for an adequate decision. 38 C.F.R. § 3.159. VA has a duty to assist the veteran which includes conducting a thorough and contemporaneous medical examination. See Hyder v. Derwinski, 1 Vet. App. 221 (1991); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In the Memorandum Decision, the Court found the Board "failed to mention" several documents in the record reflecting diagnosis of PTSD. The Court noted that one such document was a discharge instruction on a VA medical record, clearly noting a PTSD diagnosis. The Board notes that the record discussed by the Court appears to be a July 1997 discharge summary from Brecksville VAMC. The Axis I diagnoses include Heroine dependency, History of migraine, Cocaine dependency, PTSD and Borderline personality disorder. It is unclear whether there are additional records reflecting the basis for this diagnosis. However, it appears that the veteran was a resident at a VA domiciliary beginning in September 1996 or thereabouts. Complete medical records, including, but not limited to group/individual counseling notes, psychiatric evaluations and physical examination reports for the period in question should be obtained and associated with the claims folder. In addition, the RO/AMC should attempt to obtain any additional psychiatric notes associated with the April 1997 VA hospitalization which resulted in the diagnosis of PTSD. A review of the claims folder reveals that several attempts by VA to obtain the veteran's service treatment records have met with only limited success. Likewise, the veteran's efforts to obtain additional records have not been fruitful. In its 2005 decision, the Board noted that even if it were conceded that the veteran was raped in service, the fact remains that the veteran has not, at any time, carried a diagnosis of PTSD. The Board finds that an examination would be helpful under the present circumstances, considering the veteran's contentions about being raped prior to and in service, and the varying medical opinions of record as to whether the veteran has PTSD due to such a stressor in service. Accordingly, the case is REMANDED for the following action: 1. The RO must review the claims file and ensure that all notification and development action required by 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002) are fully complied with and satisfied. 2. The RO/AMC should request complete medical records, including, but not limited to group/individual counseling notes, psychiatric evaluations and physical examination reports for the period when the veteran was a resident at a VA domiciliary beginning in September 1996 or thereabouts. Further, any additional VA psychiatric treatment records be obtained, particularly any records related to the diagnosis noted in the April 1997 discharge summary. 2. The veteran should undergo a VA psychiatric examination to clarify whether she has PTSD related to the stressor of being raped as described during service. The examiner should indicate to what extent, any diagnosed PTSD is the result of claimed physical and sexual abuse by her stepfather (see March 1994 service personnel records and June 1997 VA nursing assessment). The examiner should discuss the other psychiatric diagnoses of record. All indicated tests and studies should be performed, and all clinical findings should be reported in detail. It is essential that the claims file be provided to the psychiatrist for review in conjunction with the examination, together with a copy of this remand. The examination report is to reflect whether such a review of the claims file was made. A diagnosis of PTSD under DSM IV criteria should be made or ruled out. If PTSD is diagnosed, the psychiatrist should identify the in-service stressor(s) supporting the diagnosis. If PTSD is not diagnosed, the examiner should explain why the diagnosis was not made. Adequate reasons and bases for any opinion rendered must be provided. 3. The veteran must be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent must be associated with the claims folder. The veteran is to be advised that failure to report for a scheduled VA examination without good cause shown may have adverse effects on her claim. 4. After the development requested above has been completed to the extent possible, the AMC/RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ RENÉE M. PELLETIER 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) (2007).