Citation Nr: 1328934 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 02-20 392A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include psychosis. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Esq. ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1973 to November 1975. A second period of active service dating from November 1975 to February 1978 resulted in a discharge characterized as "under other than honorable conditions." In a March 1981 administrative decision, the RO determined that the Veteran's period of active service dating from October 1973 to January 1976 was rendered under honorable conditions. This matter initially came before the Board of Veterans' Appeals' (Board) on appeal from April 2001 and May 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which in relevant part, denied the Veteran's claims of entitlement to service connection for mental illness and schizophrenia. In June 2008, the Veteran withdrew his request for a Travel Board hearing. See 38 C.F.R. § 20.704(e) (2012). In November 2008, the Board denied the Veteran's claim for service connection for an acquired psychiatric disorder. In a December 2010 memorandum decision, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's November 2008 decision with respect to the issue of entitlement to service connection for an acquired psychiatric disorder, and remanded the claim for additional development and readjudication consistent with the Court's memorandum decision. The Board again remanded the claim for additional development in July 2011. The case has since been returned to the Board for further appellate consideration. A review of the Veteran's Virtual VA electronic claims file is significant for additional VA treatment records pertinent to the issue on appeal from the Central Alabama VA Health Care System dating from April 2009 to January 2012. 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 essentially contends that he has a currently diagnosed acquired psychiatric disability, to include psychosis, that was incurred during or within one year of his discharge from his honorable period of active service dating from October 1973 to January 1976, or that it is otherwise related to events that occurred therein. During a November 2002 VA examination, he indicated that he experienced paranoia and a subsequent mental breakdown in 1977 related to increased pressure from a hostile supervisor. See November 2002 VA mental disorders examination report. The Veteran has consistently indicated that he received inpatient psychiatric treatment during service following a violent episode while stationed in Okinawa, Japan, which required that he be medicated and restrained. On separation examination in January 1978, he indicated that he received treatment by a Dr. Franklin at "Kuwe Hospital" in Okinawa. In the July 2011 remand, the Board directed that the RO "conduct an exhaustive search and secure for the record copies of complete clinical records of any and all treatment that the Veteran received at 'Kuwe Hospital' in Okinawa, Japan." In February 2012, the RO requested from the National Personnel Records Center (NPRC) all active duty inpatient clinical treatment records pertaining to treatment for a psychiatric disability at "Kuwe Hospital" in Okinawa, Japan dating from October 1, 1973 to December 31, 1974 and from "Kume Hospital" (presumably a typographical error) dating from January 1, 1975 to December 31, 1975. In March 2012, the NPRC indicated that a search for such records yielded negative results. In the January 2013 brief, the Veteran's attorney asserted that the February 2012 records request did not comply with the Board's July 2011 remand directives. Specifically, the request erroneously and unnecessarily limited the scope of the search for records to records pertaining solely to a psychiatric disability, as opposed to all inpatient clinical treatment records as directed in the July 2011 remand. The attorney indicated that non psychiatric treatment records may contain incidental findings relevant to the claimed disability. The attorney also submitted research indicating that there are multiple potential spellings for "Kuwe hospital" as identified by the Veteran during his separation examination. The attorney further requested that the claim be remanded to ensure that all appropriate development efforts are taken to obtain records from that facility, to include a search using all potential spellings of that facility and a request for records of any and all treatment received at that facility. In this regard, the Board observes a July 1977 service treatment record pertaining to treatment of a lacerated finger references a military treatment facility spelled "Kue," and abbreviated as "KAB." The Board also observes that service personnel records show that the Veteran was stationed in Okinawa, Japan from approximately March 2, 1976 to December 18, 1977. In light of the foregoing, and to ensure that the record is complete, the claim must again be remanded for additional development pertaining to obtainment of records of all in-service clinical treatment received by the Veteran at "Kue" / "Kuwae" / "Kuwe"/ "KAB" military hospital in Okinawa, Japan dating from March 2, 1976 to December 18, 1977. The Board also observes that the Veteran has consistently indicated that he was medevaced from his station in Okinawa, Japan to the Dwight David Eisenhower Army Medical Center at Fort Gordon, Georgia where he received ongoing inpatient treatment for a mental condition. His service personnel records confirm that he was a patient at that facility starting on December 19, 1977. Although service treatment records currently associated with the claims file contain a January 1978 certification of psychiatric evaluation from that facility, clinical inpatient and outpatient treatment records have not been requested or associated with the claims file for review. Thus, clinical inpatient treatment records pertaining to all treatment received at the Dwight David Eisenhower Army Medical Center at Fort Gordon, Georgia dating from December 19, 1977 to February 1978 must be requested. Additionally, post-service VA treatment records and examination reports dating since 2002 show that the Veteran reported that he was incarcerated at least 5 times since his discharge from military service in the state of Alabama and that he received psychiatric treatment during his incarcerations. Accordingly, the Veteran's assistance should be requested in development efforts necessary to obtain records of all treatment received by the Veteran during his multiple incarcerations dating since February 1978. Also, correspondence received from the Social Security Administration (SSA) in April 2003 suggests that the Veteran filed a claim for disability benefits with that agency. The Veteran has frequently indicated that he has been unable to function in society and maintain employment since his discharge from military service, which suggests that his SSA records may be relevant to the claim on appeal. There is no indication, however, that SSA records have been requested or associated with the claims file. Thus, additional development efforts are necessary to obtain any records pertaining to the Veteran from the SSA. See Quartuccio v. Principi, 16 Vet. App. 183, 187-88 (2002) (stating that "the possibility that the SSA records could contain relevant evidence . . . cannot be foreclosed absent a review of those records."). A request for such records should include both the Veteran's name used during military service (Ronnie Harris) and what service personnel records suggest is his legal name as listed on his birth certificate of "Ronnie Hollis." See September 1973 Statement of Name Change. Post-service VA treatment records also suggest that the Veteran received VA inpatient substance abuse treatment from July to November 2004; however, clinical treatment records pertaining to such treatment are not associated with the claims file. The record also suggests that the Veteran received VA outpatient mental health treatment from 2002 to 2009; however, only sporadic mental health treatment notes dated during this time are associated with the claims file. Finally, records of ongoing VA treatment were most recently obtained in January 2012. Thus, VA inpatient and outpatient mental health and substance abuse treatment records dating from 2002 to 2009 and records of any ongoing VA treatment dating since January 2012 must be obtained from the Central Alabama VA Health Care System. Accordingly, the case is REMANDED for the following action: 1. The RO should contact all appropriate records repositories and request that an exhaustive search be completed for records of all clinical inpatient and outpatient treatment received for any and all medical, psychiatric, and substance abuse conditions at "Kue"/"Kuwae"/"Kuwe"/ "KAB" military hospital located in Okinawa, Japan dating from March 2, 1976 to December 18, 1977. The RO must ensure that each of the aforementioned spelling variations of the military hospital and both of the Veteran's names as noted on the title page of this decision are used in conducting a search for such records. 2. Contact the Veteran and request that he provide the dates and locations of each of his post-service incarcerations dating since his discharge from military service in February 1978. He should be requested to complete and submit authorization(s) necessary to enable VA to obtain records of all medical, psychiatric, and substance abuse treatment received from the Alabama Department of Corrections dating since February 1978. The RO must undertake appropriate development efforts, using both of the Veteran's names as listed on the title page of this decision, to obtain records from all identified sources. 3. Obtain from the Central Alabama VA Health Care System records pertaining to all inpatient and outpatient treatment received for any and all medical, psychiatric, and substance abuse conditions dating from 2002 to 2009, and since January 2012, to include records of any inpatient substance abuse treatment received from July to November 2004 as alluded to in a July 2007 VA treatment note. 4. Obtain and associate with the claims file any decision from the SSA to award or deny benefits to the Veteran and the records upon which the decision is based. If the search for such records has negative results, the claims file must be properly documented as to the unavailability of these records. The RO must ensure that the request for SSA records includes a search conducted under both of the Veteran's names as listed on the title page of this decision. 5. All requests for records and any records and/or responses received must be associated with the claims file. If any requested records cannot be obtained for any reason, the RO must notify the Veteran and his attorney of its inability to obtain such records in accordance with 38 C.F.R. § 3.159(e) (2012). An appropriate time should be allowed for response. 6. The RO should arrange for any further development deemed appropriate or suggested by evidence received in response to the above requested development actions, to include seeking a nexus opinion regarding a psychiatric disability if indicated. 7. After the development requested above is completed in full, the RO should readjudicate the claim. If the claim remains denied, the RO should issue a supplemental statement of the case and afford the Veteran and his attorney an opportunity to respond. The case should then be returned to the Board, if in order. The appellant 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). _________________________________________________ A. C. MACKENZIE 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).