Citation Nr: 1330802 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 12-12 823 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: New Hampshire State Veterans Council ATTORNEY FOR THE BOARD A. Dean, Associate Counsel INTRODUCTION The Veteran had active military service from October 1969 to April 1972. This appeal to the Board of Veterans' Appeals (Board) is from a September 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which granted the Veteran's claim of entitlement to service connection for PTSD and assigned an initial 30 percent rating for this disability retroactively effective from January 13, 2010, the date of receipt of his claim. He wants a higher initial rating for his PTSD. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (When a Veteran timely appeals an initial rating, VA adjudicators must consider whether to "stage" the rating, meaning assign different ratings at different times since the effective date of the award if there have been occasions when the disability has been more severe than at others. This will compensate the Veteran for the variances in the severity of the disability). This claim requires further development before being decided on appeal, however, so the Board is remanding this claim to the RO via the Appeals Management Center (AMC) in Washington, DC. REMAND While the Board sincerely regrets the further delay that inevitably will result from remanding, rather than immediately deciding, this claim, it is necessary to ensure the claim is fully developed and receives all due consideration. 38 U.S.C.A. § 5103A(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c), (d) (2013). Specifically, pursuant to VA's duty to assist under the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), additional medical records need to be obtained and considered since relevant to the Veteran's claim for an increased rating. The Board sees that, in a statement dated in July 2011, the Veteran reported receiving weekly therapy for his PTSD at the Vet Center in White River Junction, Vermont. Also, in a more recent February 2013 statement, his wife indicated he continues to see a therapist. However, the most recent records in the file from the Vet Center are a June 2011 statement from the Veteran's counselor and treatment records from October 1984 to December 1986. When reference is made to pertinent medical records, VA is on notice of their existence and has a duty to assist the Veteran in attempting to obtain them. 38 C.F.R. § 3.159(c). See also Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992); Jolley v. Derwinski, 1 Vet. App. 37 (1990). These records therefore should be obtained in compliance with VA's duty to assist. All other relevant records should be obtained, as well, including current treatment records from White Mountain Family Healthcare in Littleton, New Hampshire, as the most recent records are from August 2009. In addition, the Veteran was afforded a VA examination in March 2012. However, the February 2013 statement from his wife suggests his PTSD has continued to worsen even since that most recent mental status evaluation. So in this circumstance another VA examination is warranted. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) ("Where the record does not adequately reveal the current state of the claimant's disability... the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination."). See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Accordingly, this claim is REMANDED for the following additional development and consideration: 1. Obtain and associate with the claims file copies of all relevant clinical records that are not already in the claims file, including, but not limited to, of the Veteran's treatment at the Vet Center in White River Junction, Vermont, since June 2011 or thereabouts, and at White Mountain Family Healthcare in Littleton, New Hampshire, since August 2009. The amount of efforts needed to be expended in obtaining outstanding records depends on who has custody of them. If they are not in the custody of a Federal department or agency, then 38 C.F.R. § 3.159(c)(1) controls, whereas subpart (c)(2) does if they are. The Veteran also must be appropriately notified if unable to obtain identified records. 38 C.F.R. § 3.159(e)(1). 2. Upon receipt of all additional treatment records, schedule another VA compensation examination to reassess the severity of the Veteran's PTSD. The claims folder, including a complete copy of this remand, must be provided to and reviewed by the examiner in conjunction with the examination. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. It is requested that the VA examiner indicate all present symptoms and manifestations attributable to the Veteran's service-connected PTSD, in accordance with the rating criteria specified at 38 C.F.R. § 4.130, Diagnostic Code 9411. The examiner should assign a Global Assessment of Functioning (GAF) score and explain the basis for this finding. It is most essential the examiner discuss the medical rationale of all opinions expressed, whether favorable or unfavorable to the claim, based on the objective clinical findings and information obtained from review of the record. 3. Then readjudicate this claim of entitlement to an initial rating higher than 30 percent for the PTSD in light of this and all other additional evidence. If this claim is not granted to the Veteran's satisfaction, send him and his representative a supplemental statement of the case (SSOC) and give them time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. The Veteran has the right to submit additional evidence and argument concerning this claim the Board is remanding. 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). _________________________________________________ KEITH W. ALLEN 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).