Citation Nr: 1333786 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 12-35 134 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUE Entitlement to an increased rating in excess of 30 percent for the service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD Brian E. Flannery, Associate Counsel INTRODUCTION The Veteran had active service from February 1965 to February 1969. This matter initially arose before the Board of Veterans' Appeals (Board) on appeal of a March 2011 rating decision by the RO that continued the rating of 10 percent for the service-connected PTSD. A subsequent Rating Decision of October 2012 increased the rating to 30 percent. However, the Board notes that the Veteran has not been granted the maximum evaluation for that disability. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet.App. 35 (1993). Thus, the issue remains on appeal. The appeal is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. REMAND In August 2010, the Veteran filed a claim for increase, stating that he should rated at least at 50 percent because his condition had worsened. The VA afforded the Veteran an examination in September 2010. Based upon this examination, the RO initially continued the 10 percent and then increased the rating to 30 percent. The Veteran asserts that the September 2010 medical examination is three years old and that medical records since October 2012 have not been updated in the claims file. VA Treatment Records As noted, the Veteran contends that the claims file does not contain updated records referable to treatment since October 2012. In addition, the Veteran's September 2010 and April 2011 statements, he reported receiving treatment for PTSD from VA starting in approximately 1991. The Veteran specifically requested that these records be considered as part of his claim. In light of this evidence, the Board is now on notice of the existence of additional VA treatment records which are pertinent to the Veteran's claim. Accordingly, those records should be obtained on remand. 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that where VA medical treatment records are material to the issue on appeal and are not included within the claims file, a remand is necessary to acquire such VA records because VA is deemed to have constructive knowledge of certain documents which are generated by VA agents or employees). New Examination The most recent VA examination in the claims file does not currently reflect the current severity of the service-connected PTSD; therefore, a another examination is required. Thus at every rating level VA must consider the extent of the Veteran's occupational and social impairment including consideration of his relationships. In order for the VA examination to be of use in making these determinations the examiner must have access to current medical records. In this case the medical evidence includes a July 2012 metal health note that indicated that the Veteran's had wife left him and that he was homeless. Accordingly, the Board finds that the September 2010 VA examination is, at this time, inadequate for rating purposes. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (stating that a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion); see also Nieves-Rodriguez, 22 Vet. App. at 301 (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Therefore, a new examination is necessary on remand. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes an examination, even if not required to do so, an adequate one must be produced). Accordingly, the case is REMANDED for the following action: 1. The RO should take all indicated action to obtain copies of any outstanding VA treatments dated since 1991 and associate them with the official record. If any of the records are unavailable, this should be documented in the record, and the Veteran should be notified of this, in accordance with 38 C.F.R. § 3.159(e). 2. The RO then should have the Veteran scheduled for a VA examination to determine the current severity of the service-connected PTSD. The claims folder should be made available to and should be reviewed by the examiner in conjunction with the examination. A report of the examination should be prepared and associated with the Veteran's VA claims file. A complete rationale must be provided for all opinions rendered. 3. After completing all indicated development, the RO should readjudicate the claim remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or 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). ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeal 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) (2013).