Citation Nr: 1337003 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 11-24 320 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial evaluation higher than 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran served on active duty from July 1968 to June 1971, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which continued the assignment of an initial disability rating of 50 percent for service-connected PTSD. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a veteran appeals the initial rating for a disability, VA must consider the propriety of a "staged" rating based on changes in the degree of severity of it since the effective date of service connection). Also appealed therefrom is the denial of a TDIU. In August 2012, a Travel Board hearing at the RO was held before the undersigned Acting Veterans Law Judge (VLJ) of the Board. During the hearing, the Veteran provided additional evidence along with a waiver of RO initial jurisdiction, which the Board hereby accepts into the record. See 38 C.F.R. §§ 20.800, 20.1304 (2013). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Board deems another VA Compensation and Pension examination warranted to objectively determine the severity of the Veteran's service-connected PTSD, inasmuch as the last such evaluation was more than two years ago, and the Veteran attests to an increase in severity since then. 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 Caffrey v. Brown, 6 Vet. App. 377 (1994). Likewise, a VA general medical examination is warranted to evaluate the capacity for gainful employability in view of all service-connected disabilities, given that the most recent clinical assessment regarding employability from the prior June 2011 VA examination did not definitively resolve this subject. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should request from the Charleston, South Carolina VA Medical Center (VAMC) all available treatment records for the Veteran dated since September 2009. Then associate all paper records obtained with the claims file, or in the alternative associate an electronic copy of these records with the Veteran's "Virtual VA" claims folder. 2. Then schedule a VA psychiatric examination to determine the current severity of the Veteran's PTSD. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be 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. 2. Also schedule a VA general medical examination to determine the effect of the Veteran's service-connected disabilities (presently PTSD, and a right ankle condition) on his ability to obtain and maintain employment. The claims folder must be made available for the examiner to review. The examiner is then requested to provide an opinion as to whether the Veteran is incapable of securing and maintaining substantially gainful employment due to the severity of one or more of his service-connected disabilities. In providing the requested determination, the examiner must consider the degree of interference with ordinary activities, including capacity for employment, caused solely by the Veteran's service-connected disabilities, as distinguished from any nonservice-connected physical or mental condition. The requested opinion must also take into consideration the relevant employment history and educational history, or lack thereof. Also take into account the conclusions regarding employability expressed by the June 2011 VA examiner. If an opinion cannot be rendered without resorting to pure speculation, please explain why this is not possible. 3. The RO/AMC should then review the claims file. If the directives specified in this remand have not been implemented, appropriate corrective action should be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 4. Thereafter, the RO/AMC should readjudicate the claims on appeal, based upon all additional evidence received. If the benefits sought on appeal are not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. (continued on the next page) These claims 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. 2013). _________________________________________________ KELLI A. KORDICH 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) (2013).