Citation Nr: 1314899 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 08-21 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran had active military service from July 1969 to July 1971, including service in the Republic of Vietnam from December 1969 to November 1970. He earned the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in February 2007 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his wife testified at a video-conference hearing before the undersigned Veterans Law Judge in March 2011. A transcript has been associated with the claims file. In May 2011, the Board remanded the case for additional development. The case now returns for further appellate review. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are potentially relevant to the issue on appeal. Thus, any future consideration of this Veteran's case should take into account the existence of this electronic record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the appellant if further action is required. REMAND In May 2011, the Board remanded the Veteran's claim, directing that the RO/AMC obtain outstanding treatment records and provide the Veteran with a VA examination. The RO/AMC provided such examination and obtained outstanding VA Medical Center (VAMC) treatment records and to this extent was compliant with the remand orders. However, the Board also specifically requested that the RO/AMC obtain the Veteran's treatment records from the Vet Center from August 2006 to the present. In May 2011 the RO/AMC requested records from Vet Center in Birmingham, Alabama. The Birmingham Vet Center responded that it had no record of treatment for the Veteran. This is substantial compliance with the remand order with respect to the Birmingham facility. In March 2012 the RO/AMC requested records from Vet Center in Montgomery, Alabama. In May 2012 it made a second request, and the Montgomery Vet Center responded with a one-page Treatment Summary, but no treatment records. The Treatment Summary stated that the Veteran had been treated at the Montgomery Vet Center since April 2010. As noted in the May 2011 remand, the Veteran has indicated that he received weekly treatment at the Vet Center in Montgomery, Alabama. However, the record still holds no underlying treatment records from this facility. Therefore, there are still roughly two years of relevant weekly treatment records outstanding. These should be sought. Stegall v. West, 11 Vet. App. 268, 271 (1998). Also, VA treatment records in the claims file are current through August 2012. The Veteran may have received additional treatment in the intervening time. Therefore, on remand, Montgomery VAMC treatment records relevant to mental health dated from August 2012 to the present should be obtained. Lastly, at the July 2011 VA examination, the Veteran was diagnosed to have multiple psychiatric illnesses, with different GAF scores assigned to each. It was unclear, however, what symptoms may be attributed to PTSD, versus those due to his other psychiatric illnesses. This should be clarified. Accordingly, the case is REMANDED for the following actions: 1. Obtain VA treatment records from the Montgomery VAMC dated from August 2012 to the present that are relevant to mental health. 2. Obtain all treatment records from the Montgomery Vet Center dated from August 2006 to the present. A summary of the content of the treatment records would not generally be considered compliance with this request. 3. Return the file to the examiner who conducted the July 2011 psychiatric evaluation of the Veteran, to have that person review the file, and identify those symptoms attributable to PTSD (versus those caused by depressive disorder and alcohol dependence which she also diagnosed. Whether alcohol abuse is considered secondary to PTSD should be discussed.) If it is not possible to distinguish the symptoms of PTSD from those attributable to the other psychiatric disorders, that should be stated. If that examiner is not available, the matter should be referred to another for the requested opinion. If it is necessary to examine the Veteran to accomplish this request, that should be arranged. 4. The RO/AMC should then readjudicate the Veteran's claim. If action remains adverse to the Veteran, the RO/AMC should provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. 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 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). _________________________________________________ MICHAEL E. KILCOYNE 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).