Citation Nr: 1314285 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 09-20 355 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for a chronic acquired psychiatric disability, other than posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran had active service from June 1973 to June 1976, February 1991 to April 1991, and additional service in the National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran filed a notice of disagreement (NOD) with this determination in October 2008, and timely perfected his appeal in June 2009. In April 2011 and November 2012, the Board remanded the issue on appeal for further examination. Regrettably, as outlined below, further development is necessary before the Board can proceed on the issue of service connection on appeal. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. In an April 2013 statement, the Veteran noted that he had been diagnosed with chronic PTSD by the Goldsboro Psychiatric Clinic. In a November 2012 Decision, the Board denied the Veteran's claim of service connection for PTSD. Because the November 2012 Board decision is now final, the Board interprets the Veteran's statement as an implicit new and material evidence claim of service connection for PTSD. See 38 U.S.C.A. § 7104 (West 2002), 38 C.F.R. § 20.1105 (2012). As that claim has not been developed for appellate review, the Board refers it to the RO for appropriate action. 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 A review of the record discloses further development is necessary prior to the adjudication of the Veteran's claim of service connection for a chronic acquired psychiatric disability, other than PTSD. A review of the claims folder reveals that the Veteran was awarded Social Security Disability Insurance benefits from the Social Security Administration (SSA). Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The claims file contains an April 2010 SSA award letter for Social Security disability benefits. However, the records regarding that application and decision have not been associated with the claims folder. Because SSA records are potentially relevant to the Board's determination, VA is obliged to attempt to obtain and consider those records. 38 U.S.C.A. § 5103A(c)(3) (West 2002); 38 C.F.R. § 3.159(c)(2) (2012); Voerth v. West, 13 Vet. App. 117 (1999); Baker v. West, 11 Vet. App. 163 (1998); Hayes v. Brown, 9 Vet. App. 67 (1996); Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Diorio v. Nicholson, 20 Vet. App. 193 (2006); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, this appeal must be remanded in order to obtain the Veteran's complete SSA record. The Board finds that a remand is also necessary to obtain any outstanding private treatment records with respect to the Veteran's service connection claim. In an April 2013 letter, the Veteran reported that he was receiving psychiatric treatment from the Goldsboro Psychiatric Clinic since March 2008. Additionally, an October 2012 letter from the Veteran's treating physician noted that he had been treating the Veteran psychiatrically from March 18, 2008 to August 15, 2012. However, it does not appear that all of these records have been associated with the claims folder. Because it appears that there may be outstanding private medical records that may contain information pertinent to his claim, those records are relevant and should be obtained. 38 C.F.R. § 3.159(c)(2) (20012); Bell v. Derwinski, 2 Vet. App. 611 (1992). Lastly, the Board notes that a September 2012 VA examination report and December 2012 addendum opinion were obtained in reference to the Veteran's psychiatric disability. However, as referenced above, the opinions were not based on the review of the Veteran's entire medical history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that when the Secretary undertakes to provide a medical examination or obtain a medical opinion, he must ensure that the examiner providing the report or opinion is fully cognizant of the claimant's past medical history). After the Veteran's private treatment records have been obtained, an addendum to the September and December 2012 VA medical opinions is necessary in order to address whether the Veteran's acquired psychiatric disorder(s), other than PTSD, had its onset in service or is related to any in-service disease, event, or injury. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1) Request, directly from the SSA, complete copies of any determination on a claim for disability benefits from that agency, together with the medical records that served as the basis for any such determination. All attempts to fulfill this development should be documented in the claims file. If the search for these records is negative, that should be documented in the claims folder, and the Veteran must be informed of this in writing in accordance with 38 C.F.R. § 3.159(e). 2) The RO/AMC should contact the Veteran and request that he provide a completed release form (VA Form 21-4142) authorizing VA to request copies of any treatment records from any private medical providers, who have treated him for his psychiatric disorder. The Board notes that claims file already contains an Authorization and Consent to Release Information form for Goldsboro Psychiatric Clinic, and these records should be obtained. After the Veteran has signed the appropriate releases, those records not already associated with the claims file, should be obtained and associated therewith. All attempts to procure any outstanding treatment records should be documented in the claims file. If the AMC cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file and the Veteran and his representative should be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 3) After the foregoing, the claims file and a copy of this remand should be returned to the VA examiner who conducted the September 2012 VA examination and December 2012 addendum reports, for an additional addendum to these opinions. If, and only if, this VA clinician is unavailable, then forward the claims file and a copy of this remand to another appropriate VA clinician for his or her review. In an addendum, the VA clinician should review all of the Veteran's private treatment records and identify all acquired psychiatric disabilities currently experienced by the Veteran. The examiner should state whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran's currently diagnosed acquired psychiatric disorder(s), other than PTSD, had its onset in service or is related to any in-service disease, event, or injury. The examiner should review and discuss the Veteran's service treatment records that document reported problems such as depression, excessive worrying, and trouble with sleeping. Additionally, the examiner should discuss the Veteran's lay statements when discussing the offered opinion. The examiner must provide a supporting rational for the opinion provided. If is determined that another examination is necessary such should be scheduled. 4) Thereafter, the AMC/RO must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinion to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 5) Following the completion of the foregoing, the AMC/RO should readjudicate the Veteran's claim. The AMC/RO should then provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. The appellant 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). _________________________________________________ WAYNE M. BRAEUER 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).