Citation Nr: 1321409 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 11-03 825 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include Posttraumatic Stress Disorder (PTSD). ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from June 1972 to June 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which denied service connection for bipolar disorder. The Veteran appealed the denial of service connection in this decision, and the matter is now before the Board. In an October 2010 statement, the Veteran's then-current representative indicated that the Veteran also wished for the issue of entitlement to service connection for PTSD to be considered. A claim for service connection for a mental disability may encompass claims for service connection of any mental disability that may reasonably be encompassed by several factors, including the claimant's description of the claim, the symptoms the claimant describes and the information the claimant submits or that the Secretary obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has listed PTSD with the Veteran's claim of service connection for an acquired psychological disorder above. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal that are not already of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. REMAND Service Connection for an Acquired Psychiatric Disorder, to include PTSD Duty to Notify The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). In this case, the Veteran's claim of service connection includes a claim for PTSD. Service connection for PTSD requires the presence of three elements: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in- service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2012). With respect to the third element, if the evidence shows that a veteran engaged in combat and the veteran is claiming a combat-related stressor, no credible supporting evidence is required. Id., see Doran v. Brown, 6 Vet. App. 283 (1994). While the Veteran has been supplied with VCAA-compliant notice in August 2008 regarding service connection for an acquired psychiatric disorder, the RO did not inform the Veteran of the PTSD-specific requirements to substantiate a claim of service connection for PTSD because the Veteran had not yet raised the theory of service connection for PTSD. Specifically, the Veteran has not been informed of the laws or regulations regarding PTSD, nor has he been asked to provide a statement regarding an in-service stressor. The Veteran should be supplied such information and an opportunity to respond. Duty to Assist VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . or all [Social Security Administration] disability records must be sought - only those that are relevant to the veteran's claim"). A review of the VA treatment records associated with the claims file identifies additional relevant VA treatment records which are not currently associated with the claims file. Specifically, a June 2006 VA outpatient treatment record from the VA Northern Indiana Healthcare System references VA treatment for depression four years prior and in-patient psychiatric treatment in the 1980s. The Board notes that no attempt has been made to acquire VA records from either of these periods. Before proceeding, these records should be sought. VA Examination In October 2009 the Veteran was scheduled for VA examination related to mental health; the Veteran failed to report for this examination. The Veteran subsequently contacted VA to indicate that his mailing address had changed and asked to be rescheduled for an examination. Based on a review of the record, no apparent effort was made to schedule the Veteran for a new examination. When a claimant fails to report to a VA examination scheduled in conjunction with an original compensation claim without good cause, the claim shall be decided based on the evidence of record. 38 C.F.R. §3.655(b) (2012). Here, however, the Board finds that VA's failure to properly address the notice to the Veteran of his scheduled VA examination constitutes "good cause"; thus, a new examination should be scheduled. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with notice, compliant with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), regarding the evidence necessary to substantiate a claim of service connection for PTSD. 2. Associate with the claims file all relevant mental health VA treatment records that are not already of record. This includes any VA treatment records from 2002 regarding depression, and any VA in-patient treatment records from 1980 to 1989 regarding depression. Document all efforts made in the claims file, including any negative responses received. 3. Following the above development, the RO should schedule the Veteran for a VA examination to assist in determining the nature and likely etiology of all current acquired psychiatric disorders. Once scheduled, attempts to notify the Veteran should be made via postal mail and telephone, and all such attempts should be documented in the record. The Veteran's VA claims folder should be made available to the examiner for review in connection with the examination. 4. After completing all indicated development, readjudicate the claim for service connection for an acquired psychiatric disorder to include PTSD in light of all the evidence of record. If any benefit sought on appeal remains denied, a Supplemental Statement of the Case should be furnished to the Veteran, and he should be afforded a reasonable opportunity to respond. 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 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). _________________________________________________ J. PARKER 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).