Citation Nr: 1338276 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 13-26 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence to reopen a claim for service connection for posttraumatic stress disorder (PTSD) has been received. 2. Entitlement to service connection for a psychosis and substance abuse, claimed as secondary to PTSD. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran had active duty service from September 1978 to November 1980. Historically, in a May 2002 rating decision, the RO denied claims for service connection for disabilities then characterized as PTSD, depression, and susbstance abuse. Although notified of the each denial in letter dated later in May 2012, the Veteran did not appeal any denial. In August 2006, the RO again denied service connection for PTSD, notifying the Veteran in an October 2006 letter. Again, the Veteran did not appeal. This appeal to the Board of Veterans' Appeals (BVA or Board) arose from an October 2011 rating decision in which the RO denied reopening the Veteran's claims for service connection for PTSD and psychosis due to substance abuse. The Veteran filed a Notice of Disagreement (NOD) with these determinations in November 2011, and timely perfected his appeal in August 2013. The RO framed the issues on appeal as requests to reopen claims of service connection for PTSD and psychosis due substance abuse. However, a close review of the claims file reveals that, although the RO previously considered service connection PTSD and substance abuse, the RO never explicitly addressed service connection for a psychosis-now claimed, along with substance abuse, as secondary to PTSD (see June 2011 claim). Under these circumstances, the Board has characterized the current appeal as encompassing those matters set forth on the title page. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) folder associated with the above claims. A review of the documents in such folder reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. For reasons expressed below, the claims on appeal are being remanded to the RO, via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran when further action, on his part, is required. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). Initially, a review of the claims file reveals that the Veteran was awarded Social Security Insurance benefits from the Social Security Administration (SSA). Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The claims file contains VA treatment records that note that the Veteran was in receipt of SSA payments. Additionally, in a January 2002 statement, the Veteran reported that he was recently awarded Social Security Insurance for his PTSD, drug addiction, and chronic depression. Furthermore, on the October 2007 VA income net worth and employment statement, the Veteran reported that he was receiving Social Security payments of $976. However, the records regarding that application and decision have not been associated with the claims folder. Because SSA records are potentially relevant to the Board's determination, VA is obliged to attempt to obtain and consider those records. 38 U.S.C.A. § 5103A(c)(3) (West 2002); 38 C.F.R. § 3.159(c)(2) (2012); Voerth v. West, 13 Vet. App. 117 (1999); Baker v. West, 11 Vet. App. 163 (1998); Hayes v. Brown, 9 Vet. App. 67 (1996); Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Diorio v. Nicholson, 20 Vet. App. 193 (2006); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, this appeal must be remanded in order to obtain the Veteran's complete SSA record. A remand is also needed to obtain pertinent outstanding VA and private medical records. In his August 2013 Substantive Appeal, the Veteran reported that he was diagnosed with PTSD at the VA Medical Center (VAMC) in Lake City (by Dr. Lee), and the Vet Center in Tallahassee, Florida (by Robert White) in 1995. Additionally, the claims file contains a May 2000 VA treatment record that stated that the Veteran was not seen in the clinic between June 1997 and April 2000. However, the claims file does not contain VA record prior to June 1997. Because it appears that there may be outstanding VA and private medical records that may contain information pertinent to his claims, those records are relevant and should be obtained. 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). Additionally, in a January 2002 statement, the Veteran reported treatment from the Apalachee Center for Human Services from 1995 to 2001, and Gainesville Florida Medical Center in 2000. However, these private treatment records have not been obtained and associated with the claims file. Accordingly, these matters are hereby REMANDED for the following action: 1. Obtain all outstanding VA treatment records prior to June 1997, and from September 2011 to the present. In particular, the Board is interested in obtaining 1995 records from the VAMC in Lake City (Dr. Lee), and the Vet Center in Tallahassee, Florida (Robert White) showing a diagnosis of PTSD. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regard to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Request, directly from the SSA, complete copies of any determination on a claim for disability benefits from that agency, together with the medical records that served as the basis for any such determination. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regard to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. All attempts to obtain these records should be documented in the claims file. If the search for these records is negative, that should be documented in the claims folder, and the Veteran must be informed of this in writing in accordance with 38 C.F.R. § 3.159(e). 3. Contact the Veteran and request that he provide a completed release form (VA Form 21-4142) authorizing VA to request copies of any treatment records from any private medical providers who have treated him for his psychiatric disabilities and substance abuse, to include Apalachee Center for Human Services from 1995 to 2001, and Gainesville Florida Medical Center in 2000. 4. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested action, and any additional notification and/or development deemed warranted, adjudicate the matters on appeal in light of all pertinent evidence (to include all that added to the record since the last adjudication) and legal authority. 7. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). These claims must be afforded expeditious treatment. The law requires that all claims 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). _________________________________________________ JACQUELINE E. MONROE 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 the appeal. 38 C.F.R. § 20.1100(b) (2013).