Citation Nr: 1311159 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 10-44 249 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Jeng, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from February 1969 to February 1971. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which granted the Veteran's claim of entitlement to service connection for PTSD and assigned an initial 30 percent disability evaluation. During the pendency of the appeal, in a September 2010 statement of the case, the RO increased the disability evaluation for PTSD to 50 percent disabling effective the date of service connection. Since the RO did not assign the maximum disability rating possible, the appeal for a higher disability evaluation remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993) (noting that where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit does not abrogate the pending appeal). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Board finds that additional development is warranted in this case before a decision may be rendered. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion only when it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A (d) (West 2002); 38 C.F.R. § 3.159(c) (4) (2012). See also Robinette v. Brown, 8 Vet. App. 69, 76 (1995). The Veteran was last afforded a VA examination for his PTSD in December 2009. Review of the examination report and the evidence received since December 2009 indicates that his PTSD may have worsened in severity since he was last evaluated. For example, a June 2009 examination report from a private psychologist, R.J.O, Ph.D., reflects that the Veteran had trouble performing at work when he was unable to obtain sufficient rest because of his recurrent nightmares; he had difficulty at work with his boss due to his irritably; he only had one friend; and he had few personal interests. The examiner assigned a GAF score of 50. Most recently, Dr. O. submitted a letter in January 2010 indicating that the Veteran was "markedly compromised in his capacity to establish and maintain effective interpersonal relationships." Additionally, Dr. O noted that the Veteran's disability disrupted social and vocational adjustment, and resulted in abrupt emotional extremes. The Veteran also had impairment in carrying out a normal work day or week due to his poor ability to interact with others. Dr. O assigned a GAF score of 41. In a March 2011 statement, the Veteran's representative argued that a new examination was required. Based on the evidence of record, the Board finds that the Veteran's symptoms appear to have worsened since he was last evaluated. Accordingly, the Board finds that a contemporaneous VA medical examination is warranted to determine the current severity of the service-connected PTSD. See Littke v. Derwinski, 1 Vet. App. 90, 92 (1990) (noting that VA's duty to assist includes the conduct of a contemporaneous medical examination, in particular where it is contended that a service-connected disability has become worse); see also Snuffer v. Gober, 10 Vet. App. 400 (1997) (finding that a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). Additionally, while this claim is on remand, any outstanding treatment records should be identified and obtained. 38 U.S.C.A. § 5103A(c) (West 2002); 38 C.F.R. § 3.159 (c) (2012). Accordingly, the case is REMANDED for the following actions: 1. Request that the Veteran identify any and all outstanding treatment providers. With any necessary assistance from the Veteran (i.e. have him complete a release form (VA Form 21- 4142) authorizing VA to request copies of records) attempt to obtain these identified records. All attempts to secure those records must be documented in the claims file. If VA is unable to secure these records, VA must notify the Veteran and (a) identify the specific records VA is unable to obtain; (b) briefly explain the efforts that VA made to obtain those records; (c) describe any further action to be taken by VA with respect to the claim; and (d) notify him that he is ultimately responsible for providing the evidence. 38 U.S.C.A. § 5103A (b) (2) (West 2002); 38 C.F.R. § 3.159(e) (1) (2012). 2. Schedule the Veteran for a psychiatric examination in order to determine the severity of his service-connected PTSD. The examiner should describe the Veteran's symptoms and note the impact, if any, of the Veteran's PTSD on his social and industrial functioning. A report of the examination should be prepared and associated with the Veteran's VA claims folder. 3. Thereafter, readjudicate the Veteran claim for an increased evaluation for PTSD. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. The Veteran 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). _________________________________________________ Bethany L. Buck 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).