Citation Nr: 1327658 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 09-25 626 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his mental health therapist ATTORNEY FOR THE BOARD Robert E. P. Jones, Counsel INTRODUCTION The Veteran served on active duty from January 1970 to January 1973. This matter comes before the Board of Veterans' Appeals (Board) from a June 2008 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. A review of the Veteran's virtual VA folder reveals that all documents in that folder have already been considered by the RO in adjudicating the Veteran's claim. 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 June 2008 rating decision on appeal granted the Veteran service connection for PTSD effective from June 6, 2007. The Veteran asserts that he is entitled to an initial rating in excess of 30 percent. The Veteran's most recent VA examination for rating purposes was performed in May 2008. The VA examiner reported that the Veteran had a global assessment of functioning (GAF) score of 65 due to PTSD. At a June 2013 hearing the Veteran's mental health therapist stated that the Veteran's GAF was around 35. The statement of the Veteran's mental health therapist is indicative that the Veteran's PTSD may have increased in severity since the May 2008 VA examination. Accordingly, the Veteran should be provided a new VA psychiatric examination to determine the current nature and extent of his PTSD. The hearing transcript indicates that the mental health therapist had been treating the Veteran since April 2010 at a state mental health facility called Pendleton Cottage. Copies of the Veteran's treatment records should be obtained from Pendleton Cottage. The record contains a July 2002 letter from the Social Security Administration (SSA) stating that the Veteran was found to have become disabled as of June1999. At his hearing the Veteran reported that SSA found him disabled due to Wolff-Parkinson-White syndrome and due to emphysema. As there is no indication that the SSA records would have any information pertinent to the severity of the Veteran's PTSD since June 6, 2007, there is no need to obtain the SSA records. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court), found that a claim for a total disability rating based upon unemployability was part of the determination of an underlying increased rating claim and cited to Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) for the notion that a TDIU claim is raised once a Veteran submits evidence of a medical disability; makes a claim for the highest rating possible; and submits evidence of unemployability. See 38 C.F.R. § 3.155(a). The Board notes that at the June 2013 hearing the Veteran asserted that he is unemployable due to his service-connected PTSD. Accordingly, the Veteran's TDIU claim must be adjudicated by the RO. The Veteran's most recent VA treatment record contained in his virtual electronic claims file is dated December 17, 2012. The Veteran's updated VA treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records dated from December 18, 2012 to present. 2. Request that the Veteran provide the names and addresses, as well as the dates of treatment, of any health care providers who have treated him recently for his PTSD. After obtaining the necessary authorizations from the Veteran, including for Oregon State Hospital for the period from October 2012 to present, and for Pendleton Cottage, dated from April 5, 2010 to present, request copies of the Veteran's medical records. All records/responses received should be associated with the claims file. All efforts to obtain the records should be fully documented, and all records and/or responses received should be associated with the claims file. 3. Issue a VCAA notice letter to the Veteran regarding the issue of entitlement to TDIU in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002 & Supp. 2012), 38 C.F.R. § 3.159 (2012), and applicable legal precedent. 4. Send the Veteran a TDIU application form so that he may submit his educational and occupational history. 5. When the above actions have been accomplished, arrange for a VA psychiatric examination of the Veteran to determine the severity of his service-connected PTSD. The claims file should be provided to the examiner for review in conjunction with the examination. The examiner should describe the nature and severity of the Veteran's PTSD symptoms and the effect of his PTSD condition and symptoms on his employability. A multi-axial assessment should be conducted which includes a GAF score and the examiner should provide an explanation of the significance of the score assigned. 6. Develop the TDIU claim and issue a rating decision adjudicating the Veteran's claim of entitlement to TDIU. 7. If the issue of an increased rating for service-connected post-traumatic stress disorder and the claim for TDIU continues to be denied, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate period of time for response. The case should then be returned to the Board for further consideration, if otherwise in order. 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). _________________________________________________ MICHAEL A. PAPPAS 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).