Citation Nr: 1326610 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 11-31 991 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial evaluation (rating) in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from May 1969 to May 1989. This case comes before the Board of Veterans' Appeals (Board) on appeal from a the June 2010 and November 2011 rating decisions of the Winston-Salem, North Carolina, Department of Veterans Affairs (VA) Regional Office (RO). The June 2010 rating decision granted service connection for PTSD and assigned a 30 percent disability rating, effective January 14, 2010. The November 2011 rating decision denied the claim for a TDIU. A VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, dated October 1989, appointed Disabled American Veterans (DAV) as the Veteran's representative. In a November 2011 statement, the Veteran revoked representation by DAV and indicated that he would represent himself. Accordingly, the Veteran is proceeding unrepresented. See 38 C.F.R. § 14.631(f)(1) (2012). The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. REMAND The Veteran contends that an initial evaluation in excess of 30 percent is warranted for his service-connected PTSD. The Veteran was last afforded a VA examination for his service-connected PTSD disability in June 2010, over three years ago. At the VA examination, the Veteran reported his PTSD symptomatology, to include nightmares, sleep impairment, past suicidal ideation, hypervigilance, irritability, and nervousness. The VA examiner confirmed the diagnosis of PTSD and assigned a Global Assessment of Functioning score of 55. Following the June 2010 VA examination, the Veteran submitted a statement in January 2011 noting that he was unsatisfied with the examiner who performed the June 2010 VA examination because he did not explain the evaluation to the Veteran. Specifically, and upon review of the Veteran's January 2011 statement, it appears that although the Veteran suffered from "anxieties," he did not report these symptoms to the VA examiner at the June 2010 VA examination. Supporting the Veteran's contention that he suffers from symptoms of anxiety is an April 2010 private psychiatric evaluation where Dr. E.H. prescribed Klonopin, in part, to reduce anxiety levels. Further, VA treatment records dated September 2011 and November 2011 indicate that the Veteran may be under-reporting his PTSD symptoms. For these reasons, the Board finds that an additional VA examination is necessary to ascertain the current severity and impairment of the Veteran's service-connected PTSD disability. Moreover, the September 2011 VA treatment note reveals that the Veteran is receiving disability benefits through the Social Security Administration (SSA) for his PTSD disability; however, SSA records are not included within the claims file. Accordingly, a remand for all medical records held by SSA is necessary. 38 C.F.R. § 3.159(c)(2). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should request from the SSA all records pertinent to the Veteran's claim for Social Security disability benefits as well as medical records relied upon concerning that claim. If the search for such records has negative results, the RO/AMC should notify the Veteran and place a statement to that effect in the Veteran's claims file. 2. Obtain any outstanding VA treatment records from the Durham VA Medical Center from February 2, 2010 to the present, and from the Fayetteville VA Medical Center from November 3, 2011 to the present. 3. Then, schedule the Veteran for the appropriate examination to determine the current severity of his service-connected PTSD disability. Any and all indicated evaluation studies and tests deemed necessary by the examiner should be accomplished. The Veteran's claims file should be made available and reviewed by the examiner, and the examination report should reflect that such review was accomplished. The examiner is asked to address Dr. E.H.'s evaluation dated April 2010 and the June 2010 VA examination report. (Note: VA treatment notes dated September 2011 and November 2011 suggest that the Veteran may be under-reporting his PTSD symptoms). Further, the examiner must provide an opinion as to whether the Veteran's service-connected PTSD, in and of itself, renders the Veteran unable to secure or maintain substantially (more than marginal) gainful employment consistent with educational and employment experience. The examiner should also address the impact, if any, of the Veteran's non-service connected disabilities on the Veteran's ability to maintain substantially employment. All opinions expressed must be supported by a complete rationale. 4. Thereafter, the issues on appeal should be readjudicated. If the benefits sought on appeal are not granted, the Veteran should be provided with a supplemental statement of the case and afforded the appropriate time period within which to respond thereto. The Veteran 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). _________________________________________________ K. J. ALIBRANDO 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).