Citation Nr: 1618838 Decision Date: 05/10/16 Archive Date: 05/19/16 DOCKET NO. 03-03 13A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia. REPRESENTATION Veteran represented by: Jeffrey Bunten, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Journet Shaw, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1985 to June 1988 with subsequent Army Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied reopening the claim for entitlement to service connection for bipolar disorder based on new and material evidence. The Veteran testified before a Veterans Law Judge in March 2014, and in July 2014, the Board, in pertinent part, denied reopening the claim for entitlement to service connection for a psychiatric disability based on new and material evidence. The Veteran appealed the decision to the Court of Appeals for Veterans Claims (Court). In a March 2015 Order of the Court granting a February 2015 Joint Motion for Partial Remand (JMPR), the parties agreed to vacate and remand the July 2014 decision pertaining only to the decision to deny reopening the service connection claim for a psychiatric disorder for compliance with the terms of the JMPR. The increased rating claims for the Veteran's service-connected left knee disabilities were abandoned. In August 2015, the Veteran was advised that the Veterans Law Judge who had presided over the hearing in 2014 had retired from the Board. He was given the opportunity to request another hearing, and he did so. In an August 2015 decision, the Board reopened the Veteran's service connection claim for a psychiatric disability and remanded the claim to respond to the Veteran's request for another Board hearing. The Veteran then testified before the undersigned Veterans Law Judge at a March 2016 videoconference hearing. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Unfortunately, a remand is required in this case for the issue on appeal. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. The Veteran argues that his current psychiatric disorder stems from the harassment and discrimination he received from a sergeant during his active duty service. He described having symptoms of panic attacks, suicidal thoughts, and auditory hallucinations. See March 2010 VA Form 21-526 and March 2016 Board hearing transcript. At his most recent March 2016 Board hearing, the Veteran identified facilities where he had received psychiatric treatment beginning in 1996, when he said that his mental health symptoms had become more frequent and severe. The Veteran testified that in 1996, he had checked himself into the John Cochran VA hospital. Later, he explained that he received additional psychological treatment at the Jefferson Barracks VA facility. The Veteran said that he was under the psychiatric care of Dr. J. at Jefferson Barracks from 1996 to 2009. In addition, the Veteran explained that he had sought treatment several times in 2000 at the Metropolitan Psychiatric Center, a State of Missouri Mental Health facility. Finally, the Veteran reported that he had sought psychiatric treatment for the past 10 years at Saint Marys Hospital. A careful review of the claims file shows that certain VA treatment records have not been associated with the record. As discussed, the Veteran testified to receiving treatment at John Cochran and Jefferson Barracks VA facilities since 1996. Available VA treatment records also refer to the Veteran's mental health treatment and hospitalizations as early as 1996. See June 2011 VA Discharge Summary and August 2012 VA Psychiatry Note. A December 2002 Vocational Rehabilitation Consult Note refers to 13 hospital admissions between April 1997 and October 2002. However, the earliest psychiatric treatment record from either the John Cochran or Jefferson Barracks VA facilities is in May 2001. Records from September 1993 to January 1995 in the claims file from the John Cochran VA facility do not contain any psychiatric treatment. It is clear based on the Veteran's testimony and the available treatment records that there are VA treatment records missing from the claims file. As these records may provide relevant information to substantiate the Veteran's claim, on remand, these records must be obtained and associated with the claims file for the Board to review. Bell v. Derwinski, 2 Vet. App. 611 (1992). The record includes psychiatric treatment records from the Metropolitan Psychiatric Center from 2007 to 2009. At his hearing, the Veteran said that he had received treatment from this facility in 2000. However, when the RO previously requested records beginning in 2000 from this facility, only records beginning in 2007 were received. It appears the Veteran's recollections are faulty, however. Careful review of the records indicates that when he was hospitalized there in July 2007, it was his second admission, and his first admission was in January 2007. Since the records from his first admission were not included, an additional attempt will be made. Private treatment records obtained from Saint Marys Hospital only contain treatment for the Veteran's orthopedic problems. No psychiatric treatment records were provided, despite the Veteran's testimony that he had received such treatment there for the past 10 years. In a June 2010 VA Form 21-4142, the Veteran wrote that he had received treatment for his bipolar disorder at that hospital from 2000 to 2008. Additionally, at his March 2016 hearing, the Veteran indicated that he was receiving Social Security Administration (SSA) disability benefits for his bipolar disorder since 2002. No SSA records have been associated with the record. As these records may provide evidence to substantiate the Veteran's claim, on remand, the AOJ should request any available SSA records. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (VA must request potentially relevant SSA records). Finally, the Board notes that, at the March 2014 Board hearing, the Veteran's attorney explained that the Veteran had just been released from a psychiatric institution. He did not identify whether the institution was a VA or private facility. A review of the claims file shows that the record does not include VA treatment records since July 2013. If the Veteran was in a private facility, no such records have been provided. On remand, VA treatment records since 2013 and any additional relevant private treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's outstanding mental health treatment records from: * the John Cochran and Jefferson Barracks VA facilities in St. Louis from 1996 to 2001 - this MUST include a search of retired/archived paper records with a documented negative reply if no paper records are located. * the John Cochran and Jefferson Barracks VA facilities from 2013 to the present. 2. Ask the Veteran to complete the necessary releases so VA can request his mental health treatment records from Metropolitan Psychiatric Center for admission in January 2007, and Saint Marys Hospital for psychiatric treatment from 2005 to 2016. Then, request the records, with a follow-up if necessary. Inform the Veteran if records are not received, and give him an opportunity to provide these records. 3. Contact the SSA and request a copy of the Veteran's complete SSA disability benefits file, including all associated medical records, and associate all records received with the claims file. 4. After completing the above and any other development deemed necessary, to include a VA examination, if found appropriate, the AOJ should readjudicate the claim. If the benefits sought on appeal remain denied, the Veteran should be provided with a supplemental statement of the case. 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 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). _________________________________________________ MICHELLE L. KANE 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).