Citation Nr: 1338233 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 10-19 791 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from June 1971 to June 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which granted service connection for PTSD and assigned a 50 percent rating effective December 30, 2005. The record before the Board consists of paper claims files, an electronic file known as Virtual VA, and an electronic file known as the Veterans Benefits Management System (VBMS). The Board notes that an October 2010 rating decision denied service connection for bilateral hearing loss and tinnitus. The Veteran was notified October 18, 2010. The Veteran's Virtual VA file contains a letter dated February 9, 2011, that denied the Veteran's request for reconsideration. Review of the Veterans Appeals Control and Locator System (VACOLS) reveals that the Veteran filed a notice of disagreement (NOD) in February 2011, that a statement of the case (SOC) was issued in September 2011, and that a VA Form 9 was filed in November 2011. Although an appeal concerning these claims has been formalized, they are not currently before the Board because they have not been certified. The Veteran's Virtual VA and VBMS files contain a March 2012 decision that is not located in the paper claims files. In pertinent part, the March 2012 rating decision granted service connection for diabetes mellitus and assigned a 10 percent rating effective January 17, 2013. VACOLS shows that a NOD was filed in June 2013. This issue is not currently before the Board. A May 2013 rating decision denied entitlement to a total disability rating for compensation based on individual unemployability (TDIU) and service connection for a disorders of the stomach and prostate, headaches, and peripheral neuropathy of the bilateral lower extremity and bilateral upper extremity. The Veteran was notified on May 30, 2013. VACOLS indicates that he filed a NOD in June 2013. These issues are also not currently before the Board. 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 Additional development is needed before the Board can adjudicate the claim for entitlement to an initial rating in excess of 50 percent for PTSD. As an initial matter, any temporary claims folder should be associated with the paper claims files so that the Board can better ascertain the current status of the appeal concerning the denial of service connection for bilateral hearing loss and tinnitus, neither of which have been certified to the Board, and the claims for an initial rating in excess of 10 percent for diabetes mellitus, entitlement to a TDIU, and service connection for disorders of the stomach and prostate, headaches, and peripheral neuropathy of the bilateral lower extremity and bilateral upper extremity, to which NODs were filed in June 2013. There are additional VA treatment records located in the Veteran's Virtual VA and VBMS electronic files, some of which pertain to the Veteran's treatment for PTSD and post-date the March 2010 SOC, as well as certification of this claim to the Board in November 2010. See VA Form 8. No supplemental SOC (SSOC) has been issued; this must be rectified on remand. See 38 C.F.R. § 19.31(b) (2013). The Veteran has only been examined once, namely in September 2009 in conjunction with his claim for service connection for PTSD. This examination is now over four years old. A more contemporaneous VA examination is needed. Recent VA treatment records should also be obtained. In a November 2005 letter from the McAllen, Texas, Vet Center, it was reported that the Veteran was receiving current mental health treatment from VA. Records from the Vet Center attached to this letter reveal that there is a May 2004 close out note. On remand, the Veteran should be asked whether he has resumed his treatment through the Vet Center and, if so, efforts should be made to obtain any records dated since May 2004. The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2013). Accordingly, the case is REMANDED for the following action: 1. Obtain any temporary claims folder. 2. Ask the Veteran whether he has resumed his treatment through the Vet Center since May 2004. If he has, make efforts to obtain any outstanding records. 3. Obtain the Veteran's treatment records from the VA Texas Valley Coastal Bend and the South Texas Veterans Health Care Systems, dated since May 2013. 4. Schedule the Veteran for an appropriate VA examination to ascertain the current severity of his PTSD. The examiner must review the claims file and all relevant electronic medical records. All appropriate tests and studies must be accomplished and all clinical findings reported in detail. A detailed history, to include work history, should be obtained from the Veteran. The examiner must provide a comprehensive report, including complete rationales for all conclusions reached. 5. Review the claims files and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 6. Finally, readjudicate the claim, with consideration of all evidence obtained since the issuance of the March 2010 SOC. If the benefit sought on appeal remains denied, furnish the Veteran and his representative a SSOC and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, 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 or by the U.S. 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). _________________________________________________ KATHLEEN K. GALLAGHER 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).