Citation Nr: 1325547 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 11-21 007A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1953 to May 1955. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Veteran testified before the undersigned during a videoconference hearing in June 2013; a copy of the transcript has been associated with the claims folder. The Veteran filed a claim of entitlement to service connection for PTSD. Although service connection for any other psychiatric disorder has not been claimed by the Veteran, the Board is expanding his original claim to include all acquired psychiatric disorders. See Clemons v. Shinseki, 22 Vet. App.128 (2009) (noting that when a claimant makes a claim, she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. The Board has reviewed the documents in both the paper claims file and the electronic claims file in rendering this decision. 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 The Veteran asserted in his April 2008 claim that he acquired late onset PTSD as a result of a jeep accident while in service. Service treatment records verify the Veteran was in an accident in January 1955. The Veteran's service treatment records and post-service VA and private treatment records are negative for complaints of or treatment for an acquired psychiatric disorder. However, the Board observes that the Veteran is competent to report the psychiatric symptoms he experiences including nightmares of his claimed stressor. The Veteran underwent a VA examination in January 2009. The examiner found the Veteran did not meet the full DSM IV criteria for a diagnosis of PTSD. The examiner also noted that the Veteran's claimed PTSD was less likely than not a result of his in-service Jeep accident, as he does not have a diagnosis of PTSD. A June 2009 VA progress note included diagnoses of mid-phase of life problems and PTSD, though the diagnoses were not given according to the DSM IV. Given the difference in diagnosis, the Board finds that an additional VA examination and medical nexus opinion must be obtained which addresses the nature of the Veteran's claimed acquired psychiatric disorder, to specifically include PTSD, and whether such is related to his military service. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (noting that "[o]nce VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, VA must provide an adequate one or, at a minimum, notify the [veteran] why one will not or cannot be provided"). Finally, the Board notes that there are likely outstanding VA Medical Center (VAMC) treatment records. During the June 2013 hearing, the Veteran testified that he has monthly appointments with his VA psychologist, yet the newest VA treatment records are dated in December 2012 and were submitted by the Veteran. 38 U.S.C.A. § 5103A (c) (West 2002); 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992) (noting that VA medical records are in constructive possession of the agency and must be obtained if pertinent). Therefore, on remand, all outstanding VA treatment records must be obtained. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The AMC should obtain all relevant outstanding ongoing VA treatment records. All attempts to locate these records must be documented in the paper or electronic claims file. 2. The AMC should schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of any acquired psychiatric disability, to include whether it is as likely as not that any current disorder is related to his verified stressor. The claims folder and a copy of this remand must be made available to, and be reviewed by, the examiner prior to the examination, and he or she should accomplish any indicated special tests, studies or additional consultations. Specifically, the examiner is asked to determine whether the Veteran has a diagnosis of PTSD in accordance with VA regulations. If PTSD is diagnosed, the examiner should specify the stressor or stressors used as the basis for the diagnosis and whether the stressors were sufficient to produce a diagnosis of PTSD. The examiner should opine whether it is at least as likely as not (at least a 50 percent or more probability) that the Veteran's claimed PTSD is related to his active service, to include the in-service stressor. Even if the Veteran does not meet the criteria for a PTSD diagnosis, the examiner is asked to determine the etiology of any other acquired psychiatric disorder(s). The examiner should express an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran's psychiatric disability is related to service. The rationale for all opinions expressed should be provided in a legible report. If the examiner is unable to render an opinion without resort to mere speculation, it should be indicated and explained why an opinion cannot be reached. 3. Then, the RO should readjudicate the claim on the merits. If the benefit sought is not granted, the Veteran and his representative should be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). _________________________________________________ LANA K. JENG Acting 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).