Citation Nr: 1824481 Decision Date: 04/24/18 Archive Date: 05/03/18 DOCKET NO. 16-05 736A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: John S. Berry, Jr., Attorney ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The Veteran had active service from May 1970 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND In a March 2011 private evaluation concerning traumatic stress symptoms, Ralph H. Spiller, Ph.D., a private licensed mental health counselor, diagnosed the Veteran as having PTSD. The record of evidence does not contain any other treatment records from that private examiner's office. However, in a December 2015 VA psychiatric examination report, the Veteran reported seeing that examiner for three additional sessions after the March 2011 diagnosis. A remand is necessary to obtain any outstanding treatment records. The record indicates that the Veteran served in Vietnam from March 3, 1971, to January 28, 1972. The Veteran's Certificate of Release of Discharge from Active Duty (DD-214) lists his military occupational specialty as that of a grader operator. The Veteran claims to have developed PTSD related to in-service incidents in Vietnam. For example, in a November 2012 VA psychiatric examination report, the Veteran reported witnessing the death of a friend, A. L., Jr., at Cam Rahn Bay, in 1971. Additionally, in a December 2015 VA psychiatric examination report, the Veteran reported having nightmares about seeing a helicopter crash on the first day of his arrival in Vietnam. Of note, although VA provided the Veteran with forms that requested him to give information regarding his stressor incidents so as to allow VA to corroborate their occurrence, the Veteran never returned the forms. As part of this remand, the Veteran should be provided an additional opportunity to assist in the corroboration of his claimed stressor incidents. 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. Provide a notice letter to the Veteran regarding claims for service connection for PTSD and request information from the Veteran regarding in-service stressors. Provide the Veteran with a reasonable amount of time to provide any information regarding his in-service stressors. 2. Examine the evidence, if any, submitted by the Veteran regarding the claimed in-service stressors and, if deemed necessary, make an appropriate attempt to corroborate the alleged stressors, to include the death of A. L. , Jr., at Cam Rahn Bay in 1971 (identified during the November 2012 VA examination) and the purported helicopter crash. Develop any other relevant factual information provided by the Veteran. 3. After obtaining any necessary releases, obtain and associate with the claims file all outstanding records of treatment for the claimed psychiatric disability. Associate all records or responses received with the record. All efforts to obtain records should be fully documented. At a minimum, obtain all outstanding VA records, and, if the necessary release form is returned, any outstanding records from the office of Ralph H. Spiller, Ph.D. 4. Then, if any stressors have been corroborated as a result of this remand, schedule the Veteran for a VA mental disorders examination with a psychiatrist or psychologist examiner who has not previously examined the Veteran. The examiner must review the record and should note that review in the report. In reviewing the record, the examiner should note the service medical records; the post-service medical records, to include the previous VA psychiatric examination reports and the private evaluation concerning traumatic stress symptoms; and the Veteran's lay statements. The examiner should provide a full multi-axial diagnosis, and should specifically state whether or not each criterion for a diagnosis of PTSD is met. The examiner is asked to provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that a diagnosed psychiatric disability is related to service or any incident of service? (b) If a diagnosis of PTSD is warranted, is it at least as likely as not (50 percent or greater probability) that PTSD is the result of a corroborated in-service stressor incident, or the fear of hostile military or terrorist activity during service? 4. Then, readjudicate the claim on appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. 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). (CONTINUED ON NEXT PAGE) 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. 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ DELYVONNE M. WHITEHEAD Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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).