Citation Nr: 1303760 Decision Date: 02/04/13 Archive Date: 02/08/13 DOCKET NO. 10-01 406 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for hypertension as secondary to posttraumatic stress disorder. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from July 1969 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2009 and July 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Veteran presented testimony at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in November 2012. A transcript of that hearing is associated with the claims file. 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 Veteran reported at his hearing before the undersigned in November 2012 that he received all of his care through the VA. VA treatment notes of record reveal that the Veteran is treated with medication for his hypertension and the most recent VA treatment record associated with the claims file is dated in April 2008, nearly five years ago. In April 2008 it was indicated that the Veteran would have a follow up in six months. At the Veteran's hearing in November 2012, he reported that he receives all of his treatment at the VA Clinic in Springfield, Illinois. When asked about whether he received all of his treatment from VA the Veteran responded "[a]ll but a couple and they're just kind of like backups to Danville, right now, because that's on a different situation. That's for prostate" and reported that treatment was not for his hypertension or PTSD. However, subsequently, the Veteran again affirmed that he received all of his treatment, including that for hypertension and PTSD through VA. A VA provider has submitted a statement in support of the Veteran's claim dated in September 2012 and indicated that the opinion provided was based upon a review of the Veteran's medical records. VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. See 38 U.S.C.A. § 5103A(b)(1) (West 2002); 38 C.F.R. § 3.159(c)(1) (2012). In Bell v. Derwinski, 2 Vet. App. 611 (1992), the United States Court of Appeals for Veterans Claims (Court) held that VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record, and that such documents are thus constructively part of the record before the Secretary and the Board, even where they are not actually before the adjudicating body. As the most recent VA treatment records associated with the claims file are nearly five years old and the evidence of record indicates that the Veteran continues to receive treatment from VA for his conditions, including hypertension and PTSD, attempts must be made to obtain and associate with the claims file complete VA treatment records regarding the Veteran. Additionally, in light of the likely outstanding records, the Board finds that after associating the Veteran's VA treatment records with the claims folder, the Veteran must be afforded a contemporaneous VA examination regarding the etiology of the Veteran's hypertension. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran's pertinent medical history). Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain VA medical records pertaining to the Veteran that are dated since April 2008. Any additional pertinent records identified by the appellant during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the appellant, and associated with the claims file. 2. Thereafter, the Veteran should be afforded the appropriate VA examination to determine the etiology of any hypertension found to be present. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. Based on the examination and review of the record, the examiner should address the following: (a) Is it at least as likely as not (50 percent or higher degree of probability) that any current hypertension was incurred in or aggravated by service? (b) Is it at least as likely as not (50 percent or higher degree of probability) that any current hypertension was caused by his service-connected PTSD? (c) Is it at least as likely as not that the Veteran's service-connected PTSD aggravated any current hypertension? The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of hypertension (i.e., a baseline) before the onset of the aggravation. In rendering an opinion, the examiner must comment on the VA medical opinion dated in May 2009, the VA provider's statement dated in September 2012, and private opinion dated in November 2011. 3. Thereafter, readjudicate the Veteran's claim. If the benefit sought on appeal is not granted, issue the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter 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. 2012). _________________________________________________ M. E. LARKIN 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) (2012).