Citation Nr: 1335052 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 10-33 856 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability (TDIU) prior to August 13, 2010. ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran served on active duty from May 1970 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2008 and August 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. As to the claim for a TDIU, since the RO granted the Veteran a 100 percent schedular rating effective from August 13, 2010, the Board has recharacterized this issue as it appears on the first page of this remand. 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 With respect to the claim of service connection for PTSD, the Veteran was examined for VA purposes in August 2010, and although the examiner opined that the appellant's psychiatric symptomatology did not meet the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994) (DSM IV) criteria for a diagnosis of PTSD, it was not made clear which of the DSM IV criteria where missing or otherwise provide a basis for the conclusion. Therefore, the Board finds that a remand to obtain an addendum to that examination is required. As to the claim for a TDIU prior to August 13, 2010 the record shows that the Veteran had a combined schedular rating of 80 percent at all times since he filed his claim for a TDIU on August 3, 2008. However, the record does not show that VA obtained a medical opinion as to whether his service connected disabilities prevented him from engaging in substantial gainful employment at any time from August 3, 2008, to August 13, 2010. Therefore, the Board finds that a remand to obtain such a retroactive medical opinion is required. See 38 C.F.R. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 84-86 (2006). The record also shows that there could be records of relevant treatment at the San Juan VA Medical Center as well as from a private doctor (Maria L. Roman-Orta, M.D.). Therefore, the Board finds that updated records from these places should be sought while the appeal is in remand status. Under these circumstances, this appeal is REMANDED to the RO/AMC for the following actions: 1. The RO/AMC shall obtain and physically or electronically associate with the claims file all of the Veteran's post-May 2011 treatment records from the San Juan VA Medical Center. All actions to obtain the requested records should be documented fully in the claims file. 2. After obtaining an authorization from the Veteran, the RO/AMC shall obtain and physically or electronically associate with the claims file all of his treatment records from Dr. Roman-Orta. All actions to obtain the requested records should be documented fully in the claims file. 3. After undertaking the above development to the extent possible, the RO/AMC should obtain an addendum to the August 2010 VA examination report from the same examiner if available or another qualified examiner if he is not. The claims file should be provided to the examiner in connection with the addendum. The examiner should clarify which DSM IV criteria necessary for a diagnosis of PTSD were missing and the state the reasons for so concluding. If it is deemed necessary to re-examine the Veteran to provide the requested information, that should be arranged. 4. After undertaking the above development to the extent possible, the RO/AMC should obtain a medical opinion as to whether the Veteran's service connected disabilities precluded substantial gainful employment at any time prior to August 13, 2010. The claims file should be provided to the person providing the opinion, and in offering his/her conclusion, the opinion provider should not take into account any impairment from age or non-service connected disability, but express whether it is at least as likely as not that the Veteran's service connected disabilities prevented him from engaging in substantially gainful employment at any time prior to August 13, 2010. A complete rationale with citation to relevant evidence found in the claims file should be provided. If the requested opinion cannot be provided, the reasons for that should be explained. 5. The RO/AMC should thereafter adjudicate the claims. If any benefit sought on appeal is denied, the RO/AMC shall issue a supplemental statement of the case to the Veteran that includes notice of all the relevant laws and regulations as well as notice of all the evidence added to the claims file since the July 2010 statement of the case as to the TDIU claim and since the May 2011 statement of the case as to the PTSD claim. After providing an opportunity to respond, return the case to the Board. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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 E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the Court. 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).