Citation Nr: 1802167 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 14-11 046 ) 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). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Fagan, Counsel INTRODUCTION The Veteran served on active duty from August 1990 to December 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted service connection for PTSD and assigned an initial 30 percent disability rating effective January 1, 2011. By way of a February 2017 rating decision, the RO awarded a 50 percent rating for PTSD effective January 1, 2011, the date of service connection. As that increase did not represent a total grant of the benefits sought on appeal, the claim remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to a TDIU due to service-connected PTSD has been raised by the record, including in treatment notes and in statements the Veteran has submitted to the VA. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (holding that, in the context of an initial adjudication of a claim of entitlement to service connection or in the context of a claim for an increase "a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability"). Thus, that issue has been added to the title page. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although the Board sincerely regrets the delay, further development is necessary prior to adjudication of the issues on appeal. Regarding the claim of entitlement to an increased rating for PTSD, the Board observes that, contrary to a June 2016 VA examiner's notation that no other mental disorder (aside from PTSD) has been diagnosed, the Veteran has also been diagnosed with paranoid schizophrenia and bipolar disorder. Indeed, ongoing VA treatment notes show ongoing treatment and complaints of racing thoughts, poor sleep, and high energy associated with bipolar disorder 2 with hypomania, and 2012 private treatment notes show treatment for paranoid schizophrenia. However, it is unclear from the record which symptoms are attributable to PTSD versus another disorder such as bipolar disorder or schizophrenia. Thus, the Board finds that an examination is necessary to differentiate, to the extent possible, symptoms associated with the Veteran's PTSD from symptoms of other psychiatric disorders, including bipolar disorder and/or paranoid schizophrenia. Additionally, remand is necessary to obtain outstanding medical records. During the most recent June 2016 VA PTSD examination, the examiner noted that the Veteran had a brief inpatient hospitalization, and VA treatment notes also reflect that the Veteran was hospitalized for 3-4 days in May 2012 at Beaufort Memorial Hospital for depression and a suicide attempt, with follow up treatment at the Vet Center with Dr. Jennings. However, those hospital records have not been obtained, nor have the Vet Center records. Additionally, the Board notes that July 2012 private treatment notes following the inpatient hospitalization appear to be incomplete and, interestingly, they show a diagnosis of paranoid schizophrenia without evidence of anxiety or reference to PTSD. It also appears from the record that the Veteran was treated at the Charleston Naval Health Clinic, Beaufort Naval Hospital, during the period on appeal, though limited records have been submitted by the Veteran. There also appear to be outstanding VA treatment records, as a December 2015 VA psychiatric note shows that a document was scanned to CPRS, but the Board does not have access to that viewing tool. Thus, remand is necessary to ensure all relevant treatment records have been obtained. Finally, the issue of entitlement to a TDIU due to PTSD has been raised but has undergone no preliminary notice or evidentiary development to date. Indeed, recent VA medical records suggest that the Veteran is still working; thus, his employment status is unclear. Additionally, the Veteran has reported being terminated from or reprimanded at prior employment due to his PTSD symptoms. However, no employment records or employer statements have been requested. Such development should be accomplished on remand. See 38 C.F.R. § 4.16 (2017). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a notice letter advising him of the information and evidence needed to award a TDIU. Additionally, send him a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for completion. 2. Ask the Veteran to complete release forms with the names and addresses of all employers or potential employers post service that have information regarding his disabilities on appeal. After securing the appropriate release forms, any relevant records identified should be requested. If any requested records cannot be obtained, the Veteran should be notified of such. 3. Obtain any outstanding VA treatment records dated since service, to include copies of any relevant records viewable in CPRS Tools, Vista Imaging, or any similar viewing tool. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 4. Ask the Veteran to identify any outstanding private treatment records, and advise him that he may submit any additional evidence or information he might have to support his claims, to include lay statements. After obtaining any necessary authorization forms from the Veteran, obtain any pertinent records identified and associate them with the claims file, to include records related to treatment at Beaufort Memorial Hospital around May 2012; Beaufort Naval Hospital since service; Derrell W. Ray, M.D. since service; and, any Vet Center since service. Any negative responses should be in writing and should be associated with the claims file. 5. After the development requested in items 1 through 4 has been completed to the extent possible, schedule the Veteran for a VA examination to determine the current severity of his PTSD. The claims file should be made available to and reviewed by the examiner in conjunction with the request. The examiner should provide all information required for rating purposes. Also, the examiner should, to the extent possible, differentiate which symptoms are related to the Veteran's service-connected PTSD and which are related to nonservice-connected disabilities. In addition to completing the appropriate disability benefits questionnaire, the examiner should discuss the extent to which the Veteran's PTSD has impaired the Veteran's ability to meet the demands of a job, either sedentary or physical, during the appeal period. A complete rationale for the opinions rendered must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. 6. After completing the requested actions, and any additional action deemed warranted, readjudicate the PTSD increased rating claim and adjudicate the claim of entitlement to a TDIU due to PTSD. If any benefit sought on appeal is denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board, if in order 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. §§ 5109B, 7112 (2012). _________________________________________________ S. C. KREMBS 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) (2017).