Citation Nr: 1400382 Decision Date: 01/07/14 Archive Date: 01/23/14 DOCKET NO. 11-07 797 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for schizophrenic disorder, undifferentiated type. REPRESENTATION Veteran represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD M. Espinoza, Associate Counsel INTRODUCTION The Veteran served on active duty for training from May 1979 to November 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating action of the Department of Veterans Affairs Regional Office (RO) in San Juan, Puerto Rico. The issue of entitlement to service connection for a psychiatric disorder was before the Board several times before it was granted in a September 2009 Board decision. Thereafter, the RO granted a 30 percent initial evaluation in a December 2009 rating decision effective November 13, 2001. In a March 2010 statement the Veteran requested an increase in his service-connected psychiatric disorder evaluation. Although the Veteran did not expressly disagree with the March 2010 decision, but rather the April 201 decision, new and material evidence was received in connection with the claim before the expiration of the appellate period of the March 2010 decision. Such evidence is to be considered with the claim which was pending. See 38 C.F.R. § 3.156(b) (2013). Thus, the instant appeal is for the issue of entitlement to an initial evaluation in excess of 30 percent for schizophrenic disorder, undifferentiated type, since November 13, 2001. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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 Board finds that further development is required prior to adjudicating the Veteran's claim. See 38 C.F.R. § 19.9 (2013). When the evidence indicates that a disability has worsened since the last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2013); see also Weggenmann v. Brown, 5 Vet. App. 281 (1993). The Board notes that the Veteran's Global Assessment of Functioning (GAF) scores, which reflect psychological, social, and occupational functioning on a hypothetical continuum of mental health illness, have fluctuated during the pendency of the Veteran's claim. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A GAF score of 60 was reflected in the most recent VA examination, conducted in July 2011. However, since that time the Veteran's more recent GAF scores have been lower. Specifically, a July 2012 VA treatment record revealed a GAF score of 55-60 and an October 2012 VA treatment record found a GAF score of 55. Thus, as the severity of the Veteran's symptoms may have worsened and because last VA examination was conducted several years ago, a new VA examination is warranted. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The record reveals the Veteran has sought private psychiatric treatment. Specifically, in a July 2012 VA treatment record, the Veteran stated that he had been treated by a non-VA psychiatrist, who prescribed his medication. Thus, on remand, send a letter to the Veteran asking him to identify any medical facility or treatment provider, including the non-VA psychiatrist referenced in the July 2012 VA treatment record, from which he has received psychiatric treatment. Thereafter, the necessary authorization should be obtained from the Veteran, for any identified provider, and any additional treatment records should be attempted to be obtained and associated with the claims folder. 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c)(1). All attempts to obtain these records must be documented in the claims file. The Veteran and his representative must be notified of any inability to obtain the requested documents. Also, updated VA treatment records should be obtained and associated with the claims file. The record reveals that the Veteran receives regular treatment from the San Juan, Puerto Rico VA Medical Center (VAMC). Thus, on remand, all relevant VA treatment records should be obtained, specifically from the San Juan VAMC and any associated outpatient clinics, since December 2012, and associated with the claims file. See 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(2). See also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that documents which are generated by VA agents or employees are in constructive possession of VA, and as such, should be obtained and included in the record). All attempts to obtain these records must be documented in the claims file. The Veteran and his representative must be notified of any inability to obtain the requested documents. Finally, there are two untranslated Spanish documents in the claims file, specifically a June 1993 Estado Libre Asociado de Puerto Rico certification and an October 2009 medical evaluation from the Departamento de la Familia. On remand, these documents should be translated to English, as well as any other untranslated documents that are obtained. Accordingly, the case is REMANDED for the following actions: 1. Obtain translations to English of any Spanish language documents in the claims file, including a June 1993 Estado Libre Asociado de Puerto Rico certification and an October 2009 medical evaluation from the Departamento de la Familia. 2. Obtain the Veteran's VA treatment records, since December 2012, from the San Juan VAMC and all associated outpatient clinics, and associate these records with the claims folder. All attempts to obtain these records must be documented in the claims file. The Veteran and his representative must be notified of any inability to obtain the requested documents. 3. Send a letter to the Veteran asking him to identify any medical facility or treatment provider, including the non-VA psychiatrist referenced in the July 2012 VA treatment record, from which he has received psychiatric treatment. Thereafter, the necessary authorization should be obtained from the Veteran, for any identified provider, and any additional treatment records should be attempted to be obtained and associated with the claims folder. All attempts to obtain these records must be documented in the claims file. The Veteran and his representative must be notified of any inability to obtain the requested documents. 4. Thereafter, schedule the Veteran for a VA psychiatric examination. The complete record, to include a copy of this remand, the claims folder and Virtual VA records must be made available to and reviewed by the examiner in conjunction with the examination. The examiner must comment on the frequency and the severity of the psychiatric symptomatology attributable to the Veteran's service-connected schizophrenic disorder, undifferentiated type. Furthermore, the VA examiner should provide an opinion as to the Veteran's GAF score due, solely, to his service-connected schizophrenic disorder, without regard to any non service-connected psychiatric disorders that may be diagnosed. If the service-connected schizophrenic disorder manifestations cannot be clinically distinguished from manifestations of any nonservice-connected psychiatric disability, such should be stated in the examination report, and all psychiatric findings should be considered in combination. A complete rationale for all opinions expressed must be provided. 5. The Veteran must be notified 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). 6. Finally, after undertaking any other development deemed appropriate, readjudicate the Veteran's claim. If the benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. 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. The law requires that all claims that are remanded by the Board 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). _________________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board 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).