Citation Nr: 1342006 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 11-05 531 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION The Veteran served on active duty from September 1965 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. As the medical evidence includes various mental health diagnoses during the course of the appeal, the issue before the Board has been recharacterized as stated above to encompass all currently diagnosed acquired psychiatric disorders, including but not limited to PTSD. See Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). The Veteran testified before the undersigned via videoconference hearing from the RO in February 2013. A transcript of that hearing is of record. The paper and Virtual VA paperless claims file have both been considered. 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 January 2011 VA examiner stated that the Veteran's score on a PTSD diagnostic test (PCL-M) was consistent with a diagnosis of PTSD, and that he had a score consistent with severe depressive symptoms that could "go hand in hand" with PTSD. Nevertheless, the examiner concluded that the Veteran did not meet the criteria for a PTSD diagnosis. It is unclear if this examiner considered the Veteran's reports concerning his stressors and the timing of his symptoms as contained in the VA treatment records, and the Veteran also provided additional information in this regard during the February 2013 Board hearing. During the February 2013 hearing, the Veteran reported ongoing VA mental health treatment twice a month, but the last treatment records in the file are dated in December 2010. He has also reported receiving mental health treatment in 1980 and 1981. See August 2009 statement. VA has a duty to seek records of this treatment. 38 U.S.C.A. § 5103A(b)-(c) (West 2002). VA must ensure that any medical examination or opinion that is provided when developing a claim is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (overruled on other grounds). The examiner must consider all pertinent lay and medical evidence. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to complete the necessary authorizations for any mental health treatment records dated in 1980 or 1981. Ordinarily two requests for non-VA or Federal records are required. All requests and all records received should be associated with the claims file. If any records cannot be obtained, inform the Veteran, tell him what efforts were made to get the records and what additional efforts will be made, and allow an opportunity for him to provide the records. 2. Obtain all VA mental health treatment records dated from December 2010 forward. 3. After completing the above to the extent possible, forward the entire claims file, including a copy of this remand and access to any pertinent electronic records, to the January 2011 VA examiner for an addendum. If that examiner is no longer available, the entire file should be forwarded to another appropriate examiner for an opinion. (The Veteran should be scheduled for a new VA examination only if a full examination is deemed necessary by the examiner.) Review of the claims file should be noted in the addendum or examination report. The examiner should respond to the following: (a) Identify all currently diagnosed acquired psychiatric disorders. In particular, state whether the Veteran meets the DSM-IV criteria for PTSD, and explain why or why not. (b) Is any current psychiatric disorder at least as likely as not (probability of 50 percent or more) due to service, to include the reported events aboard the U.S.S. Calvert? If PTSD is diagnosed, identify the supporting stressor(s). Further, state whether such stressor consists of a fear of hostile military or terrorist activity, consistent with the types, places, and circumstances of the Veteran's service. The examiner must provide reasons for any opinions. The Veteran's statements as to the onset and timing of his symptoms cannot be rejected due solely to a lack of corroborating medical evidence. If the examiner chooses to reject the Veteran's statements, he/she should explain why. If any requested opinion cannot be offered without resort to speculation, the examiner should explain why a non-speculative opinion cannot be offered, including what, if any additional information or evidence is necessary. 4. If any benefit sought on appeal remains denied, issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The Veteran 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. 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. 2013). _________________________________________________ Mark D. Hindin 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).