Citation Nr: 1310565 Decision Date: 04/01/13 Archive Date: 04/11/13 DOCKET NO. 10-45 790 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a back disability. 4. Entitlement to service connection for a blood disability. ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1974 to November 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the New York, New York Department of Veterans Affairs (VA) Regional Office (RO). The Board has reviewed the Veteran's physical claims file and his file on the "Virtual VA" system to insure a total review of the evidence. The issues of entitlement to service connection for hypertension, a back disability, and a blood disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran has PTSD that is etiologically related to traumatic event experienced while in active service. CONCLUSION OF LAW PTSD was incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131, (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). The U.S. Court of Appeals for Veterans Claims (Court) has held that in order to prevail on the issue of service connection on the merits, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Generally, service connection for PTSD based on an in-service stressor requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran has reported that he has PTSD as a result of his active service; specifically he has stated that while on active service he was thrown from a truck while driving to a training exercise and was also struck by a vehicle while riding his bicycle on base. The Board notes that the Veteran is competent to report events that occurred in service. See Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). A review of the Veteran's service treatment records (STRs) is silent for treatment specifically related to either any incident involving being thrown from a truck or being hit while riding a bicycle. However, the STRs do contain records of treatment with references to such incidents. Specifically, in September 1976, while seeking treatment for low back pain, the Veteran reported that he had low back pain ever since being thrown from a truck 20 months earlier. In March 1978 and June 1978, again while seeking treatment for low back pain, the Veteran referred to an incident of being thrown from a truck. In November 1978, while seeking treatment for low back pain, the Veteran reported being thrown from a truck in February 1975 and being hit by a vehicle while riding his bicycle in December 1976. In December 1978, while seeking treatment for jaw pain, the Veteran reported falling from a truck onto the left side of his face. In March 1979, while seeking treatment for low back pain, the Veteran reported being hit by a car three years earlier and being thrown from a truck three and a half years earlier. An April 1982 STR shows that Veteran was treated for new symptoms of high blood pressure, weight loss, and nervousness. This tends to show that the Veteran may have been experiencing symptoms of a psychiatric disability prior to his separation from active service. In an October 2010 memorandum to the file, the RO made a formal finding determining that there was insufficient information available to verify the Veteran's reported stressors. The Board acknowledges that official verification of the Veteran's reported stressors is unlikely. However, as discussed above, the Veteran reported being thrown from a truck and being hit by a vehicle while riding his bicycle on numerous occasions while on active service. These reports were made strictly for treatment purposes, long before the Veteran even had any intent to file a claim for entitlement to service connection. Therefore, the Board finds these statements especially probative. Additionally, there is some evidence of record that the Veteran was experiencing psychiatric symptoms prior to his separation from active service. Given that the Veteran is competent to report events that occurred in service and as there is documentation in the STRs corroborating the Veteran's stressor statements, the Board concedes the Veteran's stressors at this time. Of record is a March 2009 psychiatric evaluation performed by a private psychologist. At that time, the Veteran reported the incident of being thrown from a truck and being hit by a vehicle while riding his bicycle as stressors for PTSD. Based on the history provided by the Veteran and a mental status examination, the examiner diagnosed chronic, severe PTSD. In July 2009, the Veteran was afforded a VA examination. At that time, the Veteran again reported the stressors discussed above. Based on the history provided by the Veteran and a mental status examination, the examiner diagnosed PTSD. The examiner noted that Veteran's PTSD symptoms included persistent nightmares, sleep disturbances, mild depression, and hypervigilance. The examiner also noted that, with treatment, the Veteran's occupational functioning was likely to improve. The examiner noted that the Veteran's reported stressors did meet the DSM-IV stressor criterion for a PTSD diagnosis. In sum, the Board has conceded the fact that the Veteran experienced traumatic events in service that are considered stressors for PTSD. There is evidence that he may have experienced psychiatric symptoms prior to his separation from active service. The Veteran's private psychologist has diagnosed the Veteran as having PTSD as a result of the in service traumatic events. Finally, a VA Medical Center psychologist reported that the Veteran met the criteria for a diagnosis of PTSD. Accordingly, the Board finds that the preponderance of the evidence is for the claim, and entitlement to service connection for PTSD is warranted. In closing, in view of the fact that the full benefit sought by the Veteran as to his claim for service connection for PTSD is being granted by this decision, there is no need to undertake any review of compliance with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations because there is no detriment to the Veteran as a result of any VCAA deficiency. See generally 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The Board also notes that an RO letter in May 2009 informed the Veteran of the manner in which disability ratings and effective dates are assigned. Should the Veteran disagree with the RO's actions in the course of effectuating the grant of service connection, he may file a timely notice of disagreement if he wishes to appeal from those downstream issues. ORDER Entitlement to service connection for PTSD is granted. REMAND The Board must remand the Veteran's remaining claims on appeal for additional development. The Board notes that in October 2009, the Veteran submitted a statement that the Board has found to be a timely notice of disagreement with the denial of service connection for hypertension, a back disability, and a blood disability, in the August 2009 rating decision. A review of the record shows that the Veteran was not furnished a Statement of the Case (SOC) in response to his notice of disagreement. Because the notice of disagreement placed these issues in appellate status, the matter must be remanded for the originating agency to issue an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Accordingly, the case is REMANDED for the following action: The RO should provide the Veteran with a statement of the case as to the issues of entitlement to service connection for hypertension, a back disability, and a blood disability. The Veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b). If a timely substantive appeal is not filed, the claims should not be certified to the Board. 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 Department of Veterans Affairs