Citation Nr: 1340312 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 10-35 305 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for posttraumatic disorder (PTSD). 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD to include major depressive disorder. REPRESENTATION Veteran represented by: Alpha Veterans Disability Advocates WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. S. Willie, Counsel INTRODUCTION The Veteran served on active duty from March 1967 to November 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran testified at a videoconference hearing in July2013. A transcript of that hearing is associated with the claims file. Although the Veteran initially filed a claim for service connection for PTSD and major depressive disorder, the Board has restyled the issues to include any potentially relevant psychiatric claims raised by the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Additionally, the Veteran perfected appeals of other issues contained in the July 2009 rating decision; he withdrew those appeals via a July 2012 submission to VA. 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 A review of the record discloses that further development is necessary to properly adjudicate the issues on appeal. To that end, the Veteran contends that his psychiatric disabilities are related to his time in service. At his July 2013 hearing, he stated that he was military police and that one of his many jobs while in Vietnam, was to recover bodies of pilots that were shot down in the Air Force. His Vet Center treatment records show stressors of picking up dead bodies and exposure to a soldier begging for help as his body parts were severed. He also recalled seeing bodies that were burned and an incident involving soldiers who were shot while running out of a fire. The Veteran has not been afforded a VA examination in relation to his claims and his stressors have not been adequately developed. On remand, the RO should attempt to independently verify whether during the Veteran's service he was actually exposed to the specific stressors which he has identified. VA has a duty to provide a summary of his stressor statement to the U.S. Army and Joint Services Records Research Center (JSRRC), and ask them to attempt to verify the stressor(s). The Veteran should be asked to provide a more detailed statement of his claimed stressors. That statement, as well as any other stressor statements previously offered, should be discussed in a report to be forwarded to the JSRRC. Thereafter, the Veteran should be afforded a VA examination to determine the nature and etiology of his psychiatric disabilities. Prior to any examination, to ensure that all due process requirements are met and that the record is complete, the AMC should obtain any outstanding, relevant records pertaining to the claims on appeal. This includes VA treatment reports. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The AMC should also provide the Veteran another opportunity to present information and/or evidence pertinent to treatment for his claims. Thereafter, the AMC should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the record any VA outpatient treatment and Vet Center records pertaining to the Veteran's psychiatric disabilities that are not already of file. Any records received should be associated with the claims folder or virtual folders. All attempts to obtain records should be documented in the claims folder. 2. Contact the Veteran and request that he identify any private records pertaining to treatment for his psychiatric disabilities not already of file. Any records obtained must be associated with the claims folder. If the RO/AMC cannot locate any identified record, the RO/AMC must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must be given an opportunity to respond. 3. The RO should attempt to obtain additional information from the Veteran concerning the specific circumstances of his alleged service stressors, to include his reported witnessing of dead bodies, and seeing severed bodies. This additional information should include, as best as the Veteran can provide, specific dates and locations. The Veteran should attempt to provide some independently verifiable evidence. His statements, as well as any other stressor statements previously offered, should be discussed in a report to be forwarded to the JSRRC. If the RO determines that the stressor cannot be verified, a formal finding must be made and documented for the record. 4. After any additional evidence is associated with the claims file, schedule the Veteran for a VA examination by a clinician with appropriate expertise to address the nature and etiology of any current psychiatric disorders. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. If the examiner does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. As to PTSD, the examiner must provide an opinion as to whether it is at least as likely as not (e.g., a 50 percent or greater probability) that such disorder, if present upon examination or shown earlier in the record but not currently present, is etiologically related to a corroborated stressor. As to other diagnosed psychiatric disorders, the examiner must provide an opinion regarding each diagnosed disorder whether it is at least as likely as not that such diagnosed disorders are etiologically related to service, to include any verified stressors. All opinions must take into account the Veteran's own history and contentions and must be supported by a thorough explanation. 5. Review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 6. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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). _________________________________________________ K. MILLIKAN 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) (2012).