Citation Nr: 18150628 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 11-23 078 DATE: November 15, 2018 REMANDED Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period from April 9, 2015 to July 21, 2015 and in excess of 50 percent for the period from July 21, 2015, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1989 to January 1990 and from September 1990 to July 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) located in Montgomery, Alabama, which, in pertinent part, granted service connection for PTSD and assigned an initial noncompensable disability rating, effective July 20, 2010. Before the matter was certified to the Board, in a May 2015 rating decision, the RO increased the disability rating for PTSD to 30 percent disabling, effective May 27, 2011. In a November 2015 decision, the Board issued a decision granting an initial “30 percent rating for PTSD for the entire period on appeal.” The Board also remanded the issue of entitlement to an initial rating in excess of 30 percent for PTSD for further evidentiary development. Following the Board’s requested development, in a December 2015 rating decision, the RO increased the disability rating for the Veteran’s service-connected PTSD to 50 percent disabling, effective July 21, 2015. Thereafter, in a February 2017 decision, the Board denied entitlement to an initial rating in excess of 30 percent from July 20, 2010 to October 7, 2014; granted a 70 percent rating from October 7, 2014 to April 9, 2015; denied a rating in excess of 30 percent from April 9, 2015 to July 21, 2015; and denied a rating in excess of 50 percent from July 21, 2015. The Veteran appealed the Board’s February 2017 decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2018 Memorandum Decision, the Court affirmed the Board’s February 2017 decision with respect to the determination of an initial 30 percent disability rating for PTSD for the period prior to October 7, 2014 and set aside the Board’s decisions with respect to the denials of a rating in excess of 30 percent rating from April 9, 2015 to July 21, 2015 and in excess of 50 percent from July 21, 2015. The Court remanded the latter two issues for further development and readjudication. 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period from April 9, 2015 to July 21, 2015 and in excess of 50 percent for the period from July 21, 2015, is remanded. The Veteran asserts that higher ratings are warranted for her service-connected PTSD. She argues that the Board relied on inadequate medical examination reports, which failed to describe the occupational and social impairment caused by her suicidal ideations, when assigning the disability ratings. In the April 2018 memorandum decision, the Court determined that the Board’s findings regarding the Veteran’s service-connected psychiatric disability were inadequate for the period from April 9, 2015. For the period prior to July 21, 2015, the Court opined that the Board failed to discuss contemporaneous records showing that the Veteran’s psychiatric disability had worsened. With respect to the disability rating from July 21, 2015, the Court concluded that the Board principally relied on a December 2015 VA examination when rendering its decision regarding the Veteran’s PTSD. The examiner reported that the Veteran met most of the symptoms corresponding to a 50 percent rating. The Court noted that in the examiner’s concluding remarks, he stated that “new medical evidence” indicates an increase in severity of this Veteran’s service-connected PTSD.” However, the examiner did not discuss or evaluate the recent medical evidence. In light of the Veteran’s arguments and the Court’s findings, the Board finds that an additional VA examination must be provided on remand, to include obtaining a retroactive medial opinion regarding the degree of social and occupational impairment caused by the Veteran’s PTSD from April 9, 2015 to the present. Additionally, the Board notes that it is not clear what “new medical evidence” the VA examiner was referring to when he reported that there was an increase in severity of the Veteran’s PTSD. A review of the claims file shows that the most recent records regarding PTSD treatment are dated in October 2015. However, the VA examiner’s statement suggests that additional VA clinical records regarding additional psychiatric treatment may be available. On remand, outstanding medical records must be obtained. The matter is REMANDED for the following action: 1. Obtain outstanding VA medical records regarding psychiatric treatment. Specifically, records from October 2015 to the present must be obtained. 2. Schedule the Veteran for a VA examination to determine the severity of her PTSD. Access to records in the Veteran’s electronic claims file should be made available to the examiner for review in connection with his or her opinion. The examiner should report all signs and symptoms necessary for rating the Veteran’s disability under the General Rating Formula for Mental Disorders. The examiner should address the level of social and occupational impairment attributable to the Veteran’s PTSD. Additionally, the examiner must provide a retrospective opinion that: (a) Determines all manifestations associated with the Veteran’s PTSD from April 9, 2015 to July 21, 2015 and from July 21, 2015, and to comment on the severity; and (b) Addresses the degree of social and occupational impairment caused by her PTSD from April 9, 2015 to the present. A rationale for all opinions rendered must be provided. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Jones, Counsel