Citation Nr: 19190812 Decision Date: 12/03/19 Archive Date: 12/03/19 DOCKET NO. 15-32 488 DATE: December 3, 2019 REMANDED The claim of entitlement to an initial disability rating greater than 30 percent prior to January 26, 2016, and a rating greater than 50 percent from that date, for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty service from October 2004 to October 2008. This appeal to the Board of Veterans Appeals (Board) arose from a September 2011 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, granted service connection for PTSD, and assigned a 30 percent disability rating, effective May 25, 2010. The Veteran filed a notice of disagreement (NOD) in May 2012, and the RO issued a statement of the case (SOC) in July 2015. He filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans’ Appeals) later that month in July 2015. In a May 2016 rating decision, the RO assigned a higher, 50 percent rating for the Veteran’s service-connected PTSD, effective January 26, 2016. In June 2019, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Board’s review of the claims file reveals that further agency of original jurisdiction (AOJ) action on the claim on appeal is warranted. The Veteran last underwent a VA PTSD examination in May 2017. During his June 2019 Board hearing, the Veteran asserted that his PTSD has become significantly worse since his VA examination and that if it were not for his girlfriend, he may not be alive today. Given the evidence indicating a possible worsening of the Veteran’s PTSD symptoms, the Board finds that a remand of this matter is needed to afford the Veteran a VA examination to fully assess the current severity of his service-connected PTSD. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Prior to undertaking action responsive to the above, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. Regarding VA records, the claims file includes records of the Veteran’s treatment from the VA Illiana Health Care System (HCS) in Danville, Illinois, dated up to March 2017. Hence, more recent treatment records may exist. Therefore, the AOJ should obtain all records of VA evaluation and/or treatment of the Veteran dated since March 2017, following the current procedures prescribed in 38 C.F.R. § 3.159(c) regarding records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide information and/or evidence pertinent to the claim on appeal (particularly regarding any private (non-VA) treatment), explaining that he has a full one-year period for response. See 38 U.S.C. § 5103(b); but see 38 U.S.C. § 5103(b)(3) (clarifying that VA may decide a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the claim on appeal. Adjudication of the higher rating claim should include consideration of whether any, or any further, staged rating of the disability—assignment of additional different ratings for distinct periods of time, based on the facts found—is appropriate. This matter is hereby REMANDED for the following action: 1. Obtain from the VA Illiana HCS all outstanding records of evaluation and/or treatment of the Veteran dated since March 2017. Follow the procedures of 38 C.F.R. § 3.159 regarding requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to the claim on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide a claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a VA mental disorders examination, by an appropriate mental health professional, for evaluation of his service-connected PTSD. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the examination report should include discussion of the Veteran’s documented medical history and assertions. All necessary tests and studies (to include psychological testing) should be accomplished (with all findings made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should identify and comment upon the extent, frequency, or severity (as appropriate) of all psychiatric symptoms attributable to the Veteran’s PTSD, as well as provide an assessment of the extent of occupational and social functioning resulting from such symptoms. Also following examination of the Veteran, and review of the claims file, the examiner should indicate whether the record reflects any change(s) in the level of severity of psychiatric impairment at any point since the May 25, 2010 effective date of the award of service connection, and, if so, he or she should indicate the approximate date(s) of any such change(s), and provide an assessment as to severity of the disability on each date. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached must be provided. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the claim on appeal considering all pertinent evidence (to particularly include all that added to the electronic claims file since the last adjudication) and legal authority (to include consideration of whether any, or any further, staged rating of the disability is appropriate). JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hammad Rasul, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.