Citation Nr: 1607283 Decision Date: 02/25/16 Archive Date: 03/04/16 DOCKET NO. 12-27 858 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from October 1963 to July 1965. Service in the Republic of Vietnam is indicated by the record. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which established service connection for PTSD and denied entitlement to a TDIU. In November 2015, the Veteran presented sworn testimony during a personal hearing in St. Petersburg, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In a November 2012 rating decision, the RO increased the rating assigned to the service-connected PTSD to 50 percent. The Veteran has not expressed satisfaction with the increased disability rating; this case thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action on his part is required. REMAND After having considered the matter, and for reasons expressed immediately below, the Board finds that the claims on appeal must be remanded for further development. With respect to the issue of entitlement to an increased initial rating for PTSD, the record includes VA treatment records, which indicate that the Veteran continues to receive VA outpatient mental health treatment. However, the most recent VA treatment records contained in the claims file are dated in 2012. As such, upon remand, all outstanding VA treatment records should be obtained. Moreover, the Veteran was last afforded a VA examination in October 2012, at which time the examiner indicated that he could not address the matter of the Veteran's employability because he could not "opine without resorting to mere speculation, since Veteran was referred on Sep[tember] 28 2012, to O[utpatient]S[ubstance]A[buse]C[linic] for treatment of his alcohol dependence and did not start it, yet." The examiner explained that the "severity of the PTSD symptoms may be masked by continuous abuse of alcohol." The examiner then concluded that "a request for unemployability evaluation should be submitted at a later time;" however, no follow-up evaluation was conducted. Accordingly, to ensure the record reflects the current extent of the service-connected PTSD and to properly evaluate the Veteran's entitlement to a TDIU, a new examination is needed. See VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). The examination conducted pursuant to this remand should include review of the Veteran's claims file and past clinical history, with particular attention to the current severity of the symptoms associated with the Veteran's PTSD to include the matter of the Veteran's employability. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA treatment records, including all records pertaining to the Veteran's referral to the OSAC in September 2012. 2. Thereafter, schedule the Veteran for a VA psychiatric examination to determine the severity of his PTSD. The claims file, including a copy of this remand, must be made available to the examiner for review in connection with the examination. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the examiner), should be conducted in order to identify the degree of social and occupational impairment attributable to PTSD. The results of any such testing and studies should be included in the examination report. The examiner should provide a detailed account of all manifestations of the service-connected PTSD found to be present. In addition, a Global Assessment of Functioning (GAF) score should be assigned in accordance with DSM-IV, along with an explanation of the number assigned. (The Board recognizes that the Veterans Benefits Administration is now required to apply concepts and principles set forth in DSM-5; however, the Secretary of VA has specifically indicated that DSM-IV is still to be applied in this case, as it was certified to the Board before August 4, 2014. 79 Fed. Reg. 45094 (Aug. 4, 2014)) Additionally, the examiner should discuss all occupational impact attributable to PTSD. A complete rationale should be given for all opinions and conclusions expressed. 3. Then, readjudicate the claims, and issue a Supplemental Statement of the Case, as appropriate. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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 (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board is appealable to the Court. 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).