Citation Nr: 1809841 Decision Date: 02/14/18 Archive Date: 02/27/18 DOCKET NO. 09-27 247 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney WITNESSES AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran had active service from June 1967 to June 1971. He served in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the St. Petersburg, Florida, Regional Office of the Department of Veterans Affairs (VA) which established service connection for PTSD and assigned a 30 percent rating, effective February 29, 2008. The Veteran appeared at a September 2010 hearing before the undersigned Veterans Law Judge by videoconference from the Nashville, Tennessee, Regional Office. A hearing transcript is of record. In February 2011 and December 2013, the Board remanded the claims for a higher initial rating for PTSD and a TDIU to the Agency of Original Jurisdiction for further development. REMAND An October 2015 VA psychiatric examination reports states that the examiner noted that "suicidal and homicidal ideation, intent and planning denied currently, but [the Veteran] did report a suicide attempt in the recent past." A November 2016 written statement from the Veteran's spouse conveys that the Veteran had attempted suicide "nine times as a direct result of his PTSD" and there was strong possibility he would make another "attempt to terminate his life." VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). Because of the suggested increase in severity of the service-connected PTSD, the Board finds that further VA psychiatric evaluation is required to accurately determine the severity of the disability and its impact on the Veteran's employability. Clinical documentation dated after October 2015 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide information as to all treatment of the service-connected PTSD since October 2015, including the names and addresses of all health care providers whose records have not already been provided to VA. Upon receipt of the requested information and the appropriate releases, contact all identified health care providers and request that they forward copies of all available records pertaining to treatment of the Veteran, not already of record, for incorporation into the record. If identified records are not obtained, then notify the Veteran. 38 C.F.R. § 3.159(e) (2017). 2. Associate with the record any VA medical records not already of record of treatment of the Veteran, including that provided since October 2015. 3. Schedule the Veteran for a VA psychiatric examination in order to ascertain the current severity of PTSD. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should opine as to the levels of occupational and social impairment caused by the service-connected psychiatric disability and should describe the frequency and severity of symptoms resulting in those levels of impairment. The examiner should further provide an opinion as to the impact of the PTSD on the Veteran's vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the other service-connected disabilities. If the Veteran is felt capable of work despite the service-connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities. 4. Then readjudicate the issues on appeal. If any 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 matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or 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). _________________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board 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).