Citation Nr: 1543838 Decision Date: 10/14/15 Archive Date: 10/21/15 DOCKET NO. 11-10 074 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an evaluation in excess of 70 percent disabling, for post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Timothy A. Ralls, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1964 to August 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In a February 2011 rating decision, the RO increased the rating for PTSD disability to 70 percent, effective September 23, 2009. A decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). Thus, the matter continues before the Board. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends that his PTSD is more disabling than currently evaluated. The Veteran's PTSD is currently evaluated as 70 percent disabling. Review of the claims file shows VA medical records from Chico Vet Center, dated September 2009 to November 2009. The claims file also includes licensed clinical social worker RF's initial psychosocial assessment from January 2010 and a psychosocial update from November 2010. In a December 2010 statement, the Veteran reported that the VA doctor had recently increased his medication for symptoms of PTSD. A VA Compensation and Pension Exam (C & P Exam), dated April 2011, referenced a VA doctor at the VA Outpatient Clinic in Redding, California, that the Veteran sees every six to eight weeks. Additionally, the C & P Exam made reference to monthly individual therapy with RF, a licensed clinical social worker. Upon review of the claims file, the VA treatment records from VA Outpatient Clinic in Redding, California, have not been associated with the claims file. Additionally, the private monthly therapy records of the licensed clinical social worker, RF, have not been associated with the claims file. As such, the claim must be remanded for additional VA treatment records and private treatment records to be obtained and associated with the claims file. On remand, after obtaining any necessary authorization, attempts must be made to obtain and associate with the claims file complete treatment records from RF and complete treatment records from the Chico Vet Center, regarding the Veteran. Additionally, attempts must be made to obtain all VA Medical Center records regarding the Veteran, including those from the VA Outpatient Clinic in Redding, California. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015); Bell v. Derwinski, 2 Vet. App. 611 (1992). VA is required to conduct an accurate and descriptive medical examination based on the complete medical record. 38 C.F.R. §§ 4.1, 4.2; Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In addition, VA's duty to assist includes the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. Floyd v. Brown, 9 Vet. App. 88, 93 (1996); Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Therefore, as this remand requests the association with the claims file of additional evidence regarding the Veteran's PTSD disability and as the most recent VA examination was performed more than four years ago, the Veteran must be afforded a VA medical examination. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain and associate with the claims file complete VA Medical Center records pertaining to the Veteran, including those from the VA Outpatient Clinic in Redding, California. 2. After obtaining any necessary authorization, attempt to obtain and associate with the claims file treatment records regarding the Veteran from the licensed clinical social worker, RF, and the Chico Vet Center. Any additional pertinent records identified by the appellant during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the appellant, and associated with the claims file. 3. The Veteran should be afforded an appropriate VA examination to determine the nature, extent and severity of his PTSD disability. The claims file should be made available to and reviewed by the examiner. All indicated tests should be performed. The examiner is requested to delineate all symptomatology associated with, and the current severity of, the PTSD. The appropriate Disability Benefits Questionnaire (DBQs) should be filled out for this purpose, if possible. A complete rationale must be provided for any opinion offered. If the examiner(s) is unable to provide a requested opinion without resorting to mere speculation, he or she must explain why that is the case. 4. Thereafter, readjudicate the Veteran's claim. If the benefit sought on appeal is not granted in full, the Veteran and his representative should be issued a supplemental statement of the case and provided an opportunity to respond. 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 2014). ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).