Citation Nr: 1306629 Decision Date: 02/27/13 Archive Date: 03/01/13 DOCKET NO. 09-11 557 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a genitourinary disorder, claimed as "kidney problems," to include as secondary to posttraumatic stress disorder. 2. Entitlement to service connection for hypertension, to include as secondary to "kidney problems" and/or posttraumatic stress disorder. 3. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to posttraumatic stress disorder. 4. Entitlement to an increased evaluation for posttraumatic stress disorder, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to June 1970, with service in the Republic of Vietnam from December 1968 to December 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal of a May 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The case was certified to the Board by the Los Angeles, California RO. Based on a review of the Veteran's claims folder the Veteran has not perfected an appeal regarding his claim of entitlement to service connection for a chronic back disorder. 38 U.S.C.A. § 7105 (West 2002). Accordingly, the Board will confine its review solely to those issues listed on the title page of this decision. Finally, for reasons which will become apparent, this appeal is being REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. VA will notify you if further action is required on your part. REMAND A review of the record in this case raises some question as to the exact nature and etiology of the disabilities at issue. In that regard, service treatment records are negative for evidence of a genitourinary disorder (including "kidney problems"), hypertension, and a gastrointestinal disorder. Nonetheless, since the time of the Veteran's discharge from service, he reports receiving treatment not only for hypertension, but for various genitourinary and gastrointestinal problems. While based on the evidence of record, it would appear that the Veteran has received a diagnosis of hypertension, it is unclear at this time whether he does, in fact, suffer from a chronic genitourinary disorder (including chronic kidney problems), or a chronic gastrointestinal disorder. Further, no opinion has addressed whether the Veteran's hypertension, "kidney problems," or gastrointestinal disorder are in any way proximately due to, the result of, or aggravated by his posttraumatic stress disorder, as argued by both the appellant and his accredited representative. Significantly, to date, the Veteran has yet to be afforded VA examinations for the purpose of determining the nature and etiology of the disabilities at issue. Based on the evidence of record, the Board is of the opinion that such examinations would be appropriate prior to a final adjudication of the Veteran's current claims. See McLendon v. Nicholson, 20 Vet. App. 79 (2007). Further, in September 2007 the Veteran indicated that he had been treated for all of the disabilities currently at issue "dating back to 1970 when (he) was discharged from the Army." According to the Veteran, there were records of his treatment in the "early 1970's" at Fort Ord Hospital. By the Veteran's own account, he was also seen by "specialists at La Palma Community (Hospital), Harbor General, and Bellflower Medical Group." Significantly, the record shows that no effort has yet been made to obtain the aforementioned records. Accordingly, such an attempt will be undertaken prior to a final adjudication of the Veteran's current claims for service connection. Finally, during the course of VA outpatient treatment in May 2008, it was noted that the Veteran was currently receiving "Social Security disability." Moreover, at the time of a subsequent VA psychiatric examination in February 2012, it was once again noted that the Veteran was receiving supplemental security income. Where (as in this case), VA has actual notice that the appellant is receiving disability benefits from the Social Security Administration, and such evidence is arguably relevant, the duty to assist requires VA to obtain a copy of the decision and any supporting medical records upon which the award was based. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Given the fact that Social Security records must be secured, the Board will defer consideration of the claim of entitlement to an increased rating for posttraumatic stress disorder. Accordingly, in light of the aforementioned, and in deference to the request of the Veteran's accredited representative, the case is REMANDED to the RO/AMC for the following actions: 1. The RO/AMC should contact the appropriate service department and/or record storage facility, with a request that they provide copies of any and all records of treatment of the Veteran at Fort Ord, California, in particular, between December 1969 and June 1970. All such information, once obtained, should be made a part of the Veteran's claims folder. If the RO/AMC cannot locate such records, the RO/AMC must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The Veteran and his representative must then be given an opportunity to respond. 2. The RO/AMC should then contact the Veteran and request that he provide the full name and address for the aforementioned medical facilities, specifically, La Palma Community (Hospital), Harbor General, and Bellflower Medical Group. Following receipt of that information, the RO/AMC should contact those medical facilities, with a request that they provide copies of any and all records of treatment of the Veteran at their facilities. Those records, once obtained, should be made a part of the Veteran's claims folder. The Veteran should be requested to sign the necessary authorization for release of such private medical records to the VA. Moreover, all attempts to secure those records must be documented in the claims file. If the RO/AMC cannot obtain such records, a notation to that effect should be included in the claims folder. In addition, the Veteran and his representative should be informed of any such problem. 3. The RO/AMC should contact the Social Security Administration and request that they provide a copy of the decision concerning the Veteran's claim of entitlement to Social Security disability benefits. Any medical records utilized in the award of Social Security benefits should likewise be requested. Once obtained, all such information and records should be made a part of the Veteran's claims folder. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 4. Any pertinent VA or other inpatient or outpatient treatment records, subsequent to February 2012, the date of the most recent VA examination of record, should then be obtained and incorporated in the claims folder. The Veteran should be requested to sign the necessary authorization for release of any private medical records to the VA. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 5. Thereafter, the Veteran must be afforded VA genitourinary, cardiovascular, and gastrointestinal examinations in order to more accurately determine the nature and etiology of any diagnosed hypertension, and any diagnosed genitourinary and/or gastrointestinal disorders. The RO/AMC is advised that the Veteran must be given adequate notice of the date and place of any requested examination. The Veteran is to be notified that it is his responsibility to report for any ordered VA examination, and to cooperate in the development of his claims. The Veteran is to be advised that the consequences for failure to report for a VA examination without good cause may include denial of his claims. In the event that the Veteran does not report for the aforementioned examinations, documentation should be obtained which shows that notice scheduling the examinations was sent to his last known address. It should also be indicated whether any notice sent was returned as undeliverable. Following completion of the genitourinary examination, the examiner must address whether the Veteran currently suffers from a chronic, clinically-identifiable genitourinary disorder (including any disorder secondary to "kidney problems"), and, if so, whether such a disorder at least as likely as not had its origin during, or is in some way the result of, the Veteran's period of active military service. Should it be determined that the Veteran does, in fact, suffer from a chronic genitourinary disorder, but that such disorder did not have its origin during service, an additional opinion is requested as to whether such a disorder is at least as likely as not proximately due, the result of, or aggravated by the Veteran's service-connected posttraumatic stress disorder. Following completion of the cardiovascular examination, the examiner should specifically comment as to whether it is at least as likely as not that hypertension had its origin during, or is in some way the result of, the Veteran's period of active military service. Should it be determined that the hypertension did not have its origin during his period of active military service, an additional opinion is requested addressing whether hypertension is at least as likely as not proximately due to, the result of, or aggravated by the Veteran's service-connected posttraumatic stress disorder and/or genitourinary disability. Following completion of the gastrointestinal examination, the examiner must specifically address whether the Veteran currently suffers from a chronic, clinically-identifiable gastrointestinal disorder. If so, the examiner must opine whether it is at least as likely as not that the disorder had its origin during, or is in some way the result of, the Veteran's period of active military service. Should it be determined that the Veteran does suffer from a chronic gastrointestinal disorder, but that such disorder did not have its origin during service, an additional opinion must address whether it is at least as likely as not that any identified gastrointestinal disorder is proximately due to, the result of, or aggravated by the Veteran's posttraumatic stress disorder. A complete rationale must be provided for all opinions offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. The claims folder and a separate copy of this REMAND must be made available to and reviewed by the examiners prior to completion of the examinations. In addition, any examiner must specify in their reports that the claims file and Virtual VA records have been reviewed. 6. The RO/AMC must review the examination reports to ensure that they are in complete compliance with the directives of this REMAND and that the examiners have documented their consideration of all records contained in Virtual VA. If the reports are deficient in any manner, the RO/AMC must implement corrective procedures at once. 7. The RO/AMC must then readjudicate the Veteran's claims of entitlement to service connection for a genitourinary disorder (claimed as "kidney problems"), to include as secondary to posttraumatic stress disorder); hypertension (to include as secondary to "kidney problems" and/or posttraumatic stress disorder); and a gastrointestinal disorder (to include as secondary to posttraumatic stress disorder). The RO must also address the appellant's entitlement to an increased rating for posttraumatic stress disorder. Should any benefit sought on appeal remain denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case which must contain notice of all relevant action taken on the claims for benefits since February 2009. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. 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). _________________________________________________ DEREK R. BROWN 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).