Citation Nr: 1305233 Decision Date: 02/13/13 Archive Date: 02/21/13 DOCKET NO. 10-37 514 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: American Red Cross ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1967 to September 1968, with service in the Republic of Vietnam. His decorations include the Purple Heart. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2009 and August 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In his September 2010 substantive appeal, the Veteran requested to have a hearing scheduled in connection with his appeal for his claim of entitlement to an increased initial rating for his service-connected PTSD. However, in a March 2011 statement, the Veteran withdrew his hearing request, and did not request that his hearing be rescheduled. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. 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 Board finds that additional development is required before the issues on appeal may be decided. A review of the record shows that the Veteran was afforded a VA examination in April 2009 in connection with his claim of entitlement to service connection for PTSD. Additionally, the Veteran receives fairly regular mental health treatment at the VA medical center. The most recent VA Medical Center treatment note of record is from August 2010. In a November 2012 statement, through his representative, the Veteran asserted that his PTSD symptoms have increased in severity since his April 2009 VA examination. Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the current level of severity of all impairment resulting from his service-connected PTSD. Furthermore, the Veteran contends that he is entitled to a total disability rating based on individual unemployability. Associated with the claims file, are records from the Social Security Administration (SSA) showing that the Veteran was awarded SSA disability benefits effective May 8, 2009, in part due to his service-connected disabilities, to include his PTSD. Therefore, the Board finds that the Veteran should be afforded a VA examination to determine the current level of all impairment resulting from his service-connected disabilities, to include whether the disabilities are sufficiently severe by themselves, or in combination with each other, to render the Veteran unemployable, independent of any non-service-connected disabilities. Additionally, current medical treatment records, to include mental health notes, should also be obtained before a decision is rendered with respect to these issues. Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding, pertinent medical records. Any additional treatment records identified by the Veteran should be obtained and associated with the claims. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow them the opportunity to obtain and submit those records for VA review. 2. Then, after the foregoing development actions have been performed, the Veteran should be afforded a VA psychiatric examination to determine the current symptoms and severity of his service-connected PTSD. The claims files must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed. In discussing the relevant clinical findings, the examiner should specifically note the Veteran's current complaints, symptoms, any interference with daily and/or occupational activities, and the level of disability. A multi-axis examination, with a GAF score, should be rendered. In addition, the examiner should provide an opinion concerning the impact of the Veteran's PTSD on his ability to work, to include whether it is sufficient by itself, or in conjunction with other service-connected disabilities, to render the Veteran unemployable. The supporting rationale for all opinions expressed must be provided. 3. The Veteran should be afforded a VA examination(s) by an examiner(s) with appropriate expertise to determine the current level of severity of all impairment resulting from the Veteran's service-connected disabilities. The claims files must be made available to and reviewed by the examiner(s). Any indicated studies should be performed. The RO should ensure that all information required for rating purposes is provided, to include an assessment of the impact of the disabilities on the Veteran's daily activities. In addition, the examiner(s) should provide an opinion(s) concerning the impact of the Veteran's service-connected disabilities on the Veteran's ability to work, to include whether they are sufficient by themselves or in conjunction with other service-connected disabilities to render the Veteran unemployable. The supporting rationale for all opinions expressed must be provided. 4. The RO should ensure that all development sought is completed, and then re-adjudicate the claim. If the benefits sought remain denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. 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. 2012). _________________________________________________ M.W. GREENSTREET 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).