Citation Nr: 1325800 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 09-38 921 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for schizophrenia. 2. Entitlement to service connection for irritable bowel syndrome and hiatal hernia, claimed as secondary to service connected gastroduodenitis. 3. Entitlement to a rating in excess of 20 percent for gastroduodenitis. REPRESENTATION Appellant represented by: Alberto Torrado, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to July 1969. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA), regional office (RO) in San Juan, the Commonwealth of Puerto Rico, dated in April 2008, June 2009, and February 2010. In April 2013, the Veteran and his wife provided testimony before the undersigned at Travel Board hearing in San Juan, the Commonwealth of Puerto Rico; a transcript of that hearing is of record. The appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND The Veteran testified at his hearing before the undersigned that he receives disability benefits from the Social Security Administration (SSA). VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). To date, VA has not obtained an SSA determination or the medical records on which the determination would have been made. Because an SSA decision and the records upon which the agency based its determination are potentially relevant to VA's adjudication of his claims, VA is obliged to attempt to obtain and consider those records in adjudicating this appeal. 38 U.S.C.A. § 5103A(c) (3) (West 2002); 38 C.F.R. § 3.159(c) (2) (2012); see also Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); Diorio v. Nicholson, 20 Vet. App. 193, 199-200 (2006). As such, the Board has no discretion and must remand this appeal to obtain any extant SSA records. The Veteran contends that he has hiatal hernia and irritable bowel syndrome that are related to his service connected gastroduodenitis. The Veteran's representative has noted that the VA examination report dated in March 2008 did not address whether the Veteran's hiatal hernia and/or irritable bowel syndrome were aggravated by the service connected gastroduodenitis. Once 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 claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, another examination is necessary. The most recent VA examination addressing the Veteran's service connected gastroduodenitis was conducted in January 2010. The record contains recent private treatment records that indicate that the disability may have worsened. A current examination is warranted to assess the level of disability. Accordingly, the case is REMANDED for the following action: 1. Obtain from the SSA copies of the decision and records pertinent to any claim by the Veteran for SSA disability benefits and any pertinent, outstanding medical records concerning the Veteran's pending claims. All efforts to obtain the records should be fully documented, a negative response should be requested if no records are available. 2. Contact the appropriate VA Medical Center and obtain current VA records since December 2012. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. 3. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of any current irritable bowel syndrome and/or hiatal hernia. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The claim file should be made available to the examiner for review in connection with the examination. Based on the examination and review of the record, the examiner should offer an opinion as to the following: (a)Is it at least as likely as not that any currently diagnosed irritable bowel syndrome and/or hiatal hernia was incurred in or is otherwise related to service? (b) Is it at least as likely as not that the Veteran's service-connected gastroduodenitis caused or aggravated any currently diagnosed irritable bowel syndrome and/or hiatal hernia? The examiner should note that aggravation is defined for these purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability present (i.e., a baseline) before the onset of the aggravation. Complete rationale for all opinions must be provided. 4. Schedule the Veteran for a VA examination to determine the current severity of his gastroduodenitis. The claim file should be made available to the examiner for review in connection with the examination. All indicated studies should be performed, and their results reported. Following examination, review of the record, and interview of the Veteran, the examiner should identify all manifestations of the Veteran's service-connected gastroduodenitis. Specifically, the examiner should indicate whether the Veteran's disability is mild, moderate, moderately severe, or severe. The examiner should also note whether there are recurrent incapacitating episodes of the disability, and if so, their duration and rate of occurrence per year. The examiner should specify whether the gastroduodenitis is manifested by vomiting, recurrent hematemesis or melena, anemia, or weight loss. Finally, the examiner should indicate the extent to which the Veteran's current medication regimen relieves his gastroduodenitis symptoms. A discussion of the complete rationale for all opinions expressed should be included in the examination report, to include reference to pertinent evidence where appropriate. 5. Then readjudicate the appeal. If a benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and his representative an opportunity to respond. Then the case should be returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the 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). _________________________________________________ JOAQUIN AGUAYO-PERELES 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).