Citation Nr: 1610109 Decision Date: 03/14/16 Archive Date: 03/22/16 DOCKET NO. 13-00 409A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating for individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: Kenneth M. Carpenter, Esq. WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Arif Syed, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1967 to January 1970. His service records show that he served in the Republic of Vietnam and that his decorations include the Army Commendation Medal. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions dated in July 2009 and April 2014 from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida (RO), which respectively denied the Veteran's claim for a rating increase above 50 percent for PTSD and a TDIU. PTSD is the Veteran's only service-connected disability. In July 2015, the Board remanded the Veteran's claims. The Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The Board has reviewed the record maintained in the Veteran's Virtual VA paperless claims processing system folder. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND As indicated above, in July 2015, the Board remanded the Veteran's claims of entitlement to an increased disability rating for PTSD and entitlement to TDIU for further evidentiary development. In particular, the Board ordered the AOJ to obtain from the Veteran a report of all sources of psychiatric counseling and treatment received since March 2015 and then obtain all identified records. Further, the AOJ was to undertake the appropriate action to have hard copies of the entire content of a CD-ROM disc provided by the Social Security Administration (SSA) to be printed out and scanned in to the Veteran's VBMS claims folder. Also, the AOJ was to obtain the Veteran's employment records from his last employer, Miller Electric. Thereafter, the Veteran was to be provided a VA psychiatric examination to determine the current severity of his PTSD. Finally, the AOJ was to readjudicate the Veteran's PTSD and TDIU claims, and if the maximum benefit sought on appeal remained denied with respect to any claim, the Veteran and his attorney were to be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record was returned to the Board for further appellate review, if appropriate. Unfortunately, the Board finds that an additional remand is necessary prior to review of the Veteran's claims of entitlement to an increased disability rating for PTSD and entitlement to TDIU. Crucially, a review of the record reveals that no development has been taken with regard to the Veteran's claims on appeal as described above since the July 2015 Board remand. Indeed, it is unclear as to why the Veteran's claims folder was returned to the Board for further appellate proceedings considering no evidentiary development has been taken pursuant to the July 2015 Board remand. In light of the foregoing, the Board finds that remand is warranted for compliance with the specific instructions of the July 2015 Board remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is REMANDED for the following action: 1. After obtaining from the Veteran a report of all sources of psychiatric counseling and treatment received since March 2015 (the date of the latest VA treatment reports of record) and all necessary authorizations, obtain these identified records and associate them with the Veteran's claims file. All actions to obtain the aforementioned requested records should be documented fully in the claims files. 2. Undertake the appropriate action to have hard copies of the entire content of the CD-ROM disc provided by SSA to be printed out and scanned into the Veteran's VBMS claims file. 3. The March 2015 SOC refers to records provided to VA by the Veteran's last employer, Miller Electric. Undertake the appropriate action to arrange for the employment information received from Miller Electric scanned into the Veteran's VBMS claims file. 4. Then, schedule the Veteran for a psychiatric examination. The Veteran's claims files and his relevant clinical history should be made available for the clinician's review in connection with this examination. The examiner should note in his/her report that the Veteran's claims file has been reviewed. The examiner's report must include a full discussion of the facts of the case and any conclusions presented must be supported by a detailed rationale. The examiner should present opinions as to the following questions: (a.) Is the Veteran's PTSD currently manifested (best approximated) by occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships? (b.) Is the Veteran's PTSD currently manifested (best approximated) by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships? (c.) Is the Veteran's PTSD currently manifested (best approximated) by total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name? (d.) Any other current manifestations of PTSD should be identified and, if present, the severity thereof should be identified and discussed. (e.) The examiner should provide a detailed assessment, accompanied by supportive discussion and commentary, of the impact that the Veteran's PTSD has upon his occupational capacity and employability, given his educational and vocational history. The examiner should provide a complete rationale for any opinion(s) provided. If he/she is unable to provide a requested opinion without resorting to speculation or conjecture, he/she should so state in his/her discussion and explain why. 5. Afterwards, review the claims file to ensure that the aforementioned development and remand instructions have been fully and properly executed. Any noncompliance found should be rectified with the appropriate development. 6. Thereafter, readjudicate the Veteran's claims of (a) entitlement to an evaluation greater than 50 percent for PTSD, and; (b) entitlement to a TDIU. If the maximum benefit sought on appeal remains denied with respect to any claim, the Veteran and his attorney should be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further appellate review, if appropriate. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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 A. PAPPAS 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).