Citation Nr: 1315141 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 10-46 000 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Hudson, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1974 to October 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied the claim. 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 Board regrets further delay in this case but finds that additional development is necessary before a final decision can be rendered. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Court held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. The Veteran has been diagnosed with major depression and PTSD. See VA Examination, October 2010; see also Medical Record, Carl Albert Hospital, Outpatient, June 2009. Thus, the record raises the issue that the Veteran's current symptoms arise from major depression and/or PTSD. Additionally, the Veteran's initial September 2009 claim for benefits phrases the issue as entitlement to service connection for PTSD, anxiety and depression. Therefore, the Board cannot limit its analysis of the Veteran's claim solely to PTSD. The Veteran claims that he currently suffers from PTSD as a result of seeing a soldier crushed by a 175mm self-propelled gun on September 3, 1975 at Fort Sill. See Statement in Support of Service Connection PTSD Claim, October 2009; see also The Lawton Constitution, "Sergeant Crushed at Fort Sill," September 1975. The Veteran states that he never spoke about the incident to anyone at the time and the friend who witnessed the accident with him died in a car accident. See Statement in Support of Claim, October 2009; Veteran's Letter, January 2010; see also VA PTSD Examination, October 2010. It is necessary to seek clarification regarding the October 2010 PTSD VA examination. Specifically, the Board will request clarification of the rationale as to why the examiner found the Veteran's diagnosis of major depression solely related to the Veteran's early childhood trauma and post-service losses of his friends and father and not his in-service trauma of seeing a soldier killed in an accident. Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "[i]f further evidence or clarification of the evidence... is essential for a proper appellate decision"). This addendum VA opinion should be provided by the October 2010 examiner if she is available. The Veteran's VA treatment records on file date to March 2010, with private records dating to December 2009. If the Veteran has received additional VA or private treatment, these records must be secured. VA's duty to assist includes obtaining records of the Veteran's relevant VA and private medical treatment. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(1), (c)(2). Finally, the record shows that in 2009 the Veteran stated he was 100 percent disabled. See Outpatient Visit, Carl Albert Hospital, October 2009. It is not clear to the Board whether the Veteran is receiving compensation for his disability. The Veteran should be contacted in an effort to clarify whether or not disability compensation is being received. If disability compensation is being paid to the Veteran, the RO should request that he provide the necessary authorization to obtain those pertinent records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (c)(2). Accordingly, the case is REMANDED for the following action: 1. Request the Veteran clarify whether or not he is receiving compensation as a result of his 100 percent disability status. If disability compensation is being paid, obtain copies of records pertaining to the Veteran's disability payments. The Veteran should provide the name and address of any provider or agency which has information pertaining to his disability payment, along with any necessary release(s). 2. Obtain the names and addresses of all medical care providers who treated the Veteran for any psychiatric disorders since January 2010. After securing the necessary release(s), obtain these records. 3. Obtain records of treatment from the VA Medical Center (VAMC) in Oklahoma City from March 2010 to present and from the Carl Albert Hospital in Ada, Oklahoma, from December 2009 to present. A response, negative or positive, should be associated with the claims file. 4. After completion of the above, the RO should arrange for an addendum VA opinion from the same examiner that conducted the Veteran's October 2010 PTSD examination. The claims file and a copy of this remand should be made available to the examiner, who shall acknowledge receipt and review of these materials in any report generated as a result of this remand. The examiner should provide a rationale as to their October 2010 opinion that the Veteran's diagnosis of major depression is more likely related to his early childhood trauma and post-service losses of his friends and father than the in-service incident when he saw a soldier killed by being run over by a 175mm self-propelled gun. For the purposes of the addendum opinion, the examiner should assume that the Veteran's stressor has been verified. The VA examiner is requested to provide a thorough rationale for any addendum opinion provided. 5. After completion of the above, if the same examiner who conducted the Veteran's October 2010 PTSD examination is not available, the RO should arrange for a new PTSD examination with a medical professional with appropriate expertise. The claims file and a copy of this remand should be made available to the examiner, who shall acknowledge receipt and review of these materials in any report generated as a result of this remand. The examiner should provide a current psychiatric diagnosis. The examiner should utilize the DSM-IV in arriving at any diagnoses and should explain whether and how each of the diagnostic criteria is or is not satisfied. The examiner should then determine whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that any currently diagnosed psychiatric disorder(s) are etiologically related to any incident(s) of the Veteran's active duty service, to include his report of seeing a soldier run over and killed by a 175mm self-propelled gun. For the purposes of the examination, the examiner should assume that the Veteran's stressor has been verified. The VA examiner is requested to provide a thorough rationale for any opinion provided. 6. Readjudicate the claim on appeal with consideration of all evidence of record. If the benefit sought is not fully granted, provide the Veteran and his representative a Supplemental Statement of the Case before returning the case to the Board, 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). _________________________________________________ MILO H. HAWLEY 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).