Citation Nr: 1320927 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 11-03 984 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial disability evaluation for posttraumatic stress disorder (PTSD) in excess of 10 percent. 2. Entitlement to a total disability rating based on individual employability due to a service-connected disability (TDIU). REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD M. Sopko, Associate Counsel INTRODUCTION The Veteran had active service from August 1965 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran was granted service connection for his PTSD in January 2010. This disability was rated as 0 percent disabling. The RO, in a February 2011 rating decision, increased this rating to 10 percent disabling. This increase during did not constitute a full grant of the benefit sought. Therefore, the Veteran's claim for an increased evaluation for the service-connected PTSD remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). A review of the Virtual VA paperless claims processing system revealed no records pertinent to the present appeal. 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 finds that additional development is required before the Veteran's appeal can be adjudicated. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. VA has a duty to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c),(d) (2012). The Veteran filed his claim in July 2009. He underwent a VA examination in January 2010. The examiner determined he had a Global Assessment of Functioning (GAF) score of 60. The RO granted service connection for PTSD in a January 2010 rating decision, rating it as 0 percent disabling. Subsequent to this decision, the Veteran submitted private medical evidence suggesting his condition worsened. Specifically, physician statements from May 2010 and December 2010 show a PTSD diagnosis and indicate he had a GAF of 37 and was permanently disabled. The RO, in a February 2011 rating decision, increased the Veteran's rating based on this evidence. Given the timing of the last VA examination as well as the worsening of the Veteran's disability, remand for a current VA examination is required. In the case of a claim for a TDIU, the duty to assist requires VA to obtain an examination that includes an opinion on what effect the Veteran's service-connected disability has on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994). As no such examination occurred, it is necessary for the Board to remand the issue. In addition, as the Veteran appears to get treatment from VA on an ongoing basis, his updated VA treatment records should be obtained. His complete treatment records from Louise Glogau and Psychological Consulting Services should also be obtained, as only summaries of this treatment are of record. Finally, under 38 C.F.R. § 20.600 (2012), an appellant "will be accorded full right to representation in all stages of an appeal by a recognized organization, attorney, agent, or other authorized person." If an appellant appoints a representative, VA is to give the representative an opportunity to execute a VA Form 646, Statement of Accredited Representative in Appealed Case, prior to certification of the appeal to the Board "in all instances." See VA Adjudication Procedure Manual M21-1MR, Part I, Chapter 5, Section F.27.d (August 19, 2005) (formerly M21-1, Part IV, para. 8.29). In this case, it is unclear whether or not the Veteran's representative was afforded the opportunity to prepare a VA Form 646. A VA Form 646 is of record, but it only states "646 NOT EXECUTED." As the case must be remanded for the above reasons, the claims file must also be made available to the representative to review the record and offer written argument on the Veteran's behalf. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain the Veteran's complete treatment records from Louise Glogau, MA at Psychological Consulting Services, dated since April 2010. Actual treatment records, as opposed to summaries, should be requested. 2. Make arrangements to obtain the Veteran's complete treatment records from the Durham VA Medical Center, dated since December 2010. 3. Thereafter, schedule the Veteran for a VA psychiatric examination to determine the current severity of his service-connected PTSD. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. Following examination of the Veteran, the examiner should identify what symptoms, if any, the Veteran currently manifests or has manifested in the recent past that are attributable to his service-connected PTSD. The examiner must conduct a detailed mental status examination. The examiner must also discuss the effect, if any, of the Veteran's PTSD on his social and industrial adaptability. The examiner should assign a Global Assessment of Functioning (GAF) score for the Veteran's PTSD consistent with the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and explain the significance of the score. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected PTSD renders him unable to secure or follow substantially gainful employment consistent with his education and occupational experience. A complete rationale must be provided for all opinions offered. 3. Next, readjudicate the claims on appeal. If the claims are not granted to the Veteran's satisfaction, send him and his representative a Supplemental Statement of the Case and give him an opportunity to respond. 4. Finally, refer the claims file to the Veteran's representative so it may respond to the present appeal, including the execution and submission of a VA Form 646, Statement of Accredited Representative in Appealed Case. 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). _________________________________________________ P.M. DILORENZO 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).