Citation Nr: 1343183 Decision Date: 12/30/13 Archive Date: 01/07/14 DOCKET NO. 10-35 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Bordewyk, Alicia R. INTRODUCTION The Veteran served on active duty from February 2002 to May 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, in pertinent part, granted service connection for PTSD, with an initial 50 percent disability rating assigned, effective September 12, 2008. The Board notes that the Veteran's first and last name have been used interchangeably throughout this claim, including during VA and private treatment as well as in the Veteran's service records, claims, and statements. Clarification of his name is required. The Veteran provided testimony during a videoconference hearing before the undersigned in November 2011. A transcript is of record. During the hearing, the Veteran and his representative stated that the issue of entitlement to an increased rating for hypertension was on appeal. The Board took testimony regarding an increased rating for hypertension, just in case the issue was on appeal but the undersigned made it clear that the Board would only address the issue herein if the issue was properly on appeal. Unfortunately, the Veteran did not perfect an appeal with respect to that issue following an August 2010 statement of the case. The August 2010 VA Form 9 was specifically limited by the Veteran to the issue of an increased rating for PTSD. Therefore, the rating for hypertension will not be considered herein. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. 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 During the Board hearing, the Veteran's testimony indicated an increase in the severity of several PTSD symptoms, including panic attacks and social withdrawal. His last VA examination was provided in February 2009. VA is obliged to afford a veteran a contemporaneous examination where there is evidence of an increase in the severity of the disability and the veteran is also competent to provide lay evidence that his disability has worsened. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Therefore, a new VA examination is needed to assess the current severity of his service-connected PTSD. The Veteran reported in a December 2008 statement and the February 2009 VA examination that he has received VA treatment at the West Palm Beach VA Medical Center (VAMC), the Fort Pierce Community Based Outpatient Clinic (CBOC), and the PCT Clinic in Port St. Lucie. Complete records have not been obtained. Where VA has constructive and actual knowledge of the availability of pertinent reports in the possession of the VA, an attempt to obtain those reports must be made. See Bell v. Derwinski, 2 Vet. App. 611 (1992). These records are relevant to the appeal and efforts to obtain them should be conducted following the procedures under 38 C.F.R. § 3.159 (2013). Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA medical records, including at the West Palm Beach VA Medical Center (VAMC) prior to September 2008 and since October 2008, the Fort Pierce Community Based Outpatient Clinic (CBOC), and the PCT Clinic in Port St. Lucie, and associate them with the paper or virtual claim files. All efforts to obtain these records must be documented in the claims file. Such efforts should continue until they are obtained, it is reasonably certain that they do not exist, or that further efforts would be futile. 2. Once all relevant treatment records are associated with the claims folder, afford the Veteran a VA examination to evaluate the current severity of PTSD. The claims folder, including a copy of this remand and the any relevant records contained in Virtual VA, must be made available to the examiner in conjunction with the examination and the examiner should acknowledge review of this information in the examination report or in an addendum. The examiner should provide an opinion as to the severity of the service-connected PTSD symptomatology and its impact on occupational and social functioning. The examiner is requested to provide as much detail as possible, even if that means attaching an additional statement to the examination form. The examiner should also opine whether the Veteran's service-connected disabilities render him unable to obtain and maintain gainful employment for which he would otherwise be qualified given his education and experience. The rationale for all opinions should be provided. 3. The agency of original jurisdiction (AOJ) should review the examination report to ensure that it contains the information, opinions, and rationales requested in this remand. 4. After completion of all requested and necessary development, the AOJ should review the record in light of the new evidence obtained. If any benefit for which there is a perfected appeal remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case. Once they are afforded an opportunity to respond, the claim should be returned to the Board for appellate review. 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 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 2002 & Supp. 2013). _________________________________________________ J. A. MARKEY 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).