Citation Nr: 1340536 Decision Date: 12/09/13 Archive Date: 12/20/13 DOCKET NO. 12-21 753 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include secondary to service connected bilateral shoulder disabilities. 2. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. M. Marcus, Counsel INTRODUCTION The Veteran served on active duty from June 1951 to March 1954 and again from September 1990 to June 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2013). The appeal is remanded to the RO via the Appeals Management Center, in Washington, DC. REMAND The Veteran claims his service-connected bilateral shoulder disabilities prevent him from working. He further maintains the bilateral shoulder pain disturbs his sleep and concentration and precludes his ability to do many other physical activities. With regard to the Veteran's psychiatric claim, the Veteran mainly claims his acquired psychiatric condition is due to his service-connected bilateral shoulder disabilities. During his hearing before the Board in October 2013 the Veteran further testified as to specific events while in the Coast Guard where he had to pick up dead bodies. He indicates he still has memories of the smell of dead bodies on his hands. The RO should give the Veteran an opportunity to provide exact dates, within two month increments, and duty stations of these events. If the Veteran provides additional information, the RO should make efforts to objectively confirm these events. The Veteran's service treatment records are relatively scarce, but the Veteran's March 1954 separation examination does not indicate a psychiatric abnormality. The Veteran served in the Coast Guard with confirmed periods of active service from June 1951 to March 1954, and again from September 1990 to June 1991. The Veteran's post-service treatment records indicate various psychiatric diagnoses, to include bipolar disorder and depression. The Veteran was afforded a VA psychiatric examination in April 2011 where the examiner diagnosed with bipolar disorder, with recurrent major depressive episodes and hypomanic episodes. The examiner opined that it was not "probable" that the Veteran's bilateral shoulder injuries caused his current psychiatric disorders. The examiner, however, did not opine as to whether the Veteran's bilateral shoulder disabilities aggravated the Veteran's psychiatric diagnoses. For these reasons, the Board finds the VA examination inadequate. With regard to the Veteran's claim seeking a total disability rating based on individual unemployability (TDIU), the Board finds the examinations of record also inadequate. The Veteran testified before the Board in October 2013 that he worked for many years building music studios. When he no longer could do the physical work himself, he continued working as a consultant on such projects. He claims he was self-employed as a consultant until 2006 or 2007. However, during his April 2011 examination, however, the Veteran indicated he was still working. The examiner, therefore, did not render a specific opinion as to whether the Veteran was precluded from working due solely to his service-connected disabilities. Accordingly, the case is remanded for the following action: 1. The RO must request from the Veteran a comprehensive statement containing as much detail as possible regarding the stressors to which he alleges he was exposed in service. The Veteran must be asked to provide specific details of the claimed stressful events he experienced during service, such as dates, places, detailed descriptions of events, and any other identifying information concerning any other individuals involved in the events, including their names, ranks, units of assignment or any other identifying detail. The Veteran must be advised that this information is vitally necessary to obtain supportive evidence of the stressful events he claims to have experienced, and he must be asked to be as specific as possible because without such details an adequate search for verifying information cannot be conducted. He must also be advised to submit any verifying information that he can regarding the stressors he claims to have experienced in service, such as statements of fellow service members. He is further advised that failure to respond may result in adverse action. 2. Regardless of the Veteran's response, the RO must review the file and prepare a summary of all the claimed stressors. This summary, and all associated documents, must be sent to the appropriate federal agency to provide any information which might corroborate the Veteran's alleged stressors. 3. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims, to include any VA or non-VA facilities at which he received treatment for the disorders at issue since 2011. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. All attempts to secure this evidence must be documented in the evidence of record by the RO and any VA facilities identified must provide a negative response if no records are available. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 4. After all records are obtained to the extent available, the Veteran must be afforded a VA examination to determine whether any currently or previously diagnosed psychiatric disorder is related to his military service or to a service-connected disorder. The claims file and all electronic records must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The RO must specify for the examiner those events claimed by the Veteran that it has determined are established by the record. Based on the clinical examination and appropriate diagnostic tests, the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinions as to: (i) Whether any degree of a currently or previously diagnosed psychiatric disorder was incurred in service or otherwise due to his military service in light of his described Coast Guard duties that have been confirmed by the evidence of record; (ii) Whether any degree of a currently or previously diagnosed psychiatric disorder is proximately due to or aggravated by his service-connected bilateral shoulder disabilities. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 5. Thereafter, the Veteran must be afforded an appropriate VA examination to determine the effects of his service-connected disabilities on his ability to obtain and maintain employment consistent with his education and occupational experience. The claims file and all electronic records must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. All necessary special studies or tests are to be accomplished. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether the Veteran's service-connected bilateral shoulder disabilities, and any other disorder service-connected as a result of this appeal, render him unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. This opinion must be provided without consideration of his nonservice-connected disabilities, or age. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 6. The RO must notify the Veteran that it is his responsibility to report for the examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). In the event that the Veteran does not report for an examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 7. After completing the above actions, 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 any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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).