Citation Nr: 1608233 Decision Date: 03/01/16 Archive Date: 03/09/16 DOCKET NO. 11-21 632 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to October 25, 2011, and a rating in excess of 70 percent from December 7, 2011. 2. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ryan Frank, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1968 to July 1971. He served in Vietnam and was awarded a Bronze Star Medal. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In June 2012, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. This appeal was remanded by the Board in August 2012 for further development. It has now been returned to the Board for adjudication. In a May 2013 rating decision, the RO granted the Veteran a 100 percent rating for the Veteran's PTSD from October 25, 2011 to December 6, 2011, based on hospitalization for a period greater than 21 days. Accordingly, the issue of entitlement to an increased rating for the Veteran's PTSD during that period is no longer before the Board. The discussion in this document is for those times when the temporary total rating was not assigned. Nothing herein should be taken as affecting that period. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Accordingly, any future consideration of the appellant's case should be applied to those electronic records. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran's most recent VA examination was in December 2014 and the most recent VA treatment record in the claims file also from that month. The Veteran's representative's statements since that date suggest that the appellant's condition might have worsened since the most recent examination. "Where the record does not adequately reveal the current state of the claimant's disability, a VA examination must be conducted." Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The claim must therefore be remanded for a new examination. It is noted that in the prior remand, it was requested that a Global Assessment of Function (GAF) score be recorded and that examination findings should include a discussion of the affect the PTSD had on his daily life and employment. These findings were not clearly set out. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should obtain copies of all pertinent, outstanding records from the VA Medical Center and its associated clinics where the Veteran receives treatment. All attempts to obtain records should be documented in the claims folder. 2. After any additional records are obtained and associated with the claims file, schedule the Veteran for a VA examination to determine the current nature and severity of his PTSD. The electronic claims folder must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file has been reviewed. The examiner must provide a complete explanation for any opinion offered. The examiner should provide a full multi-axial diagnosis, to include a GAF score related to the Veteran's PTSD. All signs and symptoms of psychiatric disability should be reported in detail. The examiner should describe the impact of the Veteran's psychiatric disability on his occupational and social functioning, and should discuss the impact it has on his activities of daily living, including the overall functional impact. 3. The Veteran is notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. 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 (2015). 4. The AOJ should review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. 5. Thereafter, the AOJ should readjudicate the issues, including the issue of entitlement to a TDIU. If any benefit sought is not granted, the appellant and his representative must be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters 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). _________________________________________________ MICHAEL D. LYON 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).