Citation Nr: 1314197 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 09-48 129 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for service-connected post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from April 1968 to October 1970 This appeal comes to the Board of Veterans' Appeals (Board) from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure 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 Veteran seeks a higher initial disability evaluation for his service-connected PTSD. On appeal, the Veteran and his representative argue that he should have been afforded a VA examination. The medical evidence of record includes VA treatment records from June 2003 when the Veteran was first diagnosed with depressive disorder and PTSD through October 2009 outpatient treatment records for PTSD. Also of record are three private psychological evaluations from August 2007, May 2009, and March 2010. No records are available for the past three years. The Veteran was not afforded a VA examination in this case. The most recent psychological medical record, the private evaluation from March 2010, reflects that the Veteran reported he was feeling more overwhelmed and more forgetful at that time. He also reported recent instances of anger, the severity of which is not reflected in earlier records. When the evidence of record does not reflect the current state of the claimant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); see also Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (finding that " '[w]here the veteran claims a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, [ ] VA must provide a new examination' to fulfill its duty to assist" (quoting Olson v. Principi, 3 Vet. App. 480, 482 (1992))); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (holding that, in a claim for an increased rating, the Board erred by relying on a 23-month-old examination where the appellant submitted evidence to indicate that there had been a material change in his disability since that examination). Although the Board sincerely regrets the additional delay, a remand is necessary in order to afford the Veteran a current VA examination as the current evidence of record is not adequate to adjudicate the Veteran's claim. In the case of a disability compensation claim, VA's duty to assist includes providing a medical examination or obtaining a medical opinion when 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). Accordingly, the case is REMANDED for the following action: 1. Obtain copies of all VA treatment records for PTSD dated from October 2009 to the present. Such records must either be printed and associated with the Veteran's paper claims file, or uploaded into the Veteran's electronic file contained in the Virtual VA system. 2. Obtain all private treatment records for PTSD identified by the Veteran, including any records from Dr. Wende J. Anderson dated from April 2010 to the present. 3. Thereafter, schedule the Veteran for a VA psychiatric examination to determine the current nature and extent of his service-connected PTSD. The entire claims file (i.e. both the paper claims file and any medical records contained in Virtual VA) must be provided to the examiner for review in conjunction with the examination. The examiner should indicate in the report that the claims file was reviewed. All signs and symptoms of the service-connected psychiatric disorder should be reported in detail. Any other tests and studies deemed helpful by the examiner should be conducted. Although the Veteran has retired, the examiner should comment on whether the Veteran's psychiatric disorder impacted his employment and the Veteran's current capacity for employment. The examiner should also describe the impact of the Veteran's psychiatric disorder on his social functioning. The rationale for all opinions should be explained. 4. After all development has been completed, readjudicate the issue of entitlement to an initial disability rating greater than 30 percent for the service-connected PTSD. If such action does not resolve the claim, a Supplemental Statement of the Case should be issued to the Veteran and his representative. An appropriate period of time should be allowed for response. Thereafter, this claim should be returned to this Board for further appellate review, if in order. 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). _________________________________________________ SARAH B. RICHMOND Acting 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).