Citation Nr: 1316547 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 09-16 350 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to November 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in March 2013. A copy of the transcript is included with the Veteran's electronic records in Virtual VA. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). 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 As noted in the Introduction, the Veteran served on active duty from November 1966 to November 1968 to include service in Vietnam from January 1968 to November 1968. The Veteran's military occupational specialty (MOS) was as an aircraft parts specialist. The Veteran submitted his claim for service connection for PTSD in November 2006. He later submitted an informal Vietnam Combat Certificate issued by the commanding general of the 1st Cavalry Division for the Veteran's period of service in Vietnam. He was noted as assigned to Company D, 15th Transportation Corps Battalion. The Veteran's unit assignment is also verified by his personnel records. The Veteran submitted a stressor statement in December 2006. He provided information in regard to two specific stressors. The first event took place in May 1968 at Camp Evans. The ammunition dump at the camp was destroyed. The Veteran also said they took many rockets in general. The second event involved the death of an individual. The Veteran said the event occurred in April 1968 and that a helicopter crashed. He knew the individual that died. The RO obtained evidence to corroborate the stressors provided by the Veteran. The evidence documented the attack on the ammunition dump at Camp Evans in May 1968. The RO also confirmed the death of a soldier with the last name given by the Veteran. There are extensive VA medical records associated with the claims folder as well as in electronic form on Virtual VA. The records show that the Veteran had a period of treatment in mental health in 2006 and 2007. He was not diagnosed with PTSD. However, he was diagnosed with anxiety disorder, not otherwise specified (NOS) and this diagnosis has been carried in his records through October 2012. The Veteran did have a negative outpatient screening for PTSD in August 2005; however, a second screening for PTSD in August 2006 was positive. The Veteran testified at his hearing that he believed he had been diagnosed with PTSD in 2006. However, a review of the medical evidence of record shows only the positive PTSD screening from that time. The Veteran was not afforded an examination in this case. The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); accord Caluza v. Brown, 7 Vet. App. 498 (1995). Entitlement to service connection for PTSD requires medical evidence diagnosing PTSD in accordance with the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. §§ 3.304(f). 4.125(a) (2012); see also Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The Board notes that the regulations pertaining to claims for service connection for PTSD were amended during the pendency of the Veteran's appeal. In particular, VA added a new subsection to 38 C.F.R. § 3.304(f) that dealt with PTSD claims that involved fear of hostile military or terrorist activity. See 75 Fed. Reg. 39,843-39,852 (July 13, 2010); codified at 38 C.F.R. § 3.304(f)(3). The Director of Compensation and Pension issued a Training Letter to advise RO's on how to develop claims related to the change in regulations in November 2010. See Training Letter 10-05. Of note in that guidance is the determination that the threshold to provide an examination in cases involving fear of hostile military or terrorist action is very low if other evidence of record indicates such service for the claimant. In this case, the Veteran has corroborated stressors. In addition, his Vietnam service experiences qualify for consideration under 38 C.F.R. § 3.304(f)(3). He has a diagnosis of anxiety disorder and a positive PTSD screen. A VA examination is necessary to ensure the duty to assist the Veteran has been met. Accordingly, the case is REMANDED for the following action: 1. The RO should contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for a psychiatric disorder since service. The RO should attempt to obtain copies of pertinent treatment records identified by the Veteran that have not been previously secured (or determined not to exist) and associate them with the claims folder. 2. Upon completion of the above development, the RO should arrange for the Veteran to be afforded a psychiatric examination. The claims folder, and a copy of this remand, must be provided to and reviewed by the examiner as part of the overall examination. All indicated studies, tests and evaluations, if any, should be performed as deemed necessary by the examiner. The results of any testing must be included in the examination report. Any medical evidence relied on by the examiner must be included in the claims folder or in Virtual VA. The examiner is advised that the Veteran has had two claimed stressors corroborated in the development of his claim. One involves an ammunition dump explosion at his unit in Vietnam. The second is the death of an individual he knew. The Veteran has also related that his unit was subject to recurring rocket attacks. If a diagnosis of PTSD is made, the examiner should specify the stressor, or stressors, relied on in making the diagnosis of PTSD. If a diagnosis of PTSD is not made, the examiner should explain in the examination report why such a diagnosis is not warranted. If it is because the Veteran did not meet the necessary criteria, please explain why that is so. If the examination results in a diagnosis of a psychiatric disorder(s) in addition to or other than PTSD, the examiner should state in the examination report whether it is at least as likely as not (50 percent or greater likelihood) that the Veteran developed the psychiatric disorder(s) as a result of his military service. The report of examination must include the complete rationale for all opinions expressed. 3. Thereafter, the RO should review the claims folder, and any electronic records, to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination report and required medical opinions to ensure that they are responsive to and in compliance with the directives of this remand and if they are not, the RO should implement corrective procedures. 4. After undertaking any other development deemed appropriate the RO should re-adjudicate the issue on appeal. If the benefit sought is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. Thereafter, the case should be returned to the Board for further appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified by the RO. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. 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). _________________________________________________ ROBERT E. SULLIVAN 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).