Citation Nr: 20003012
Decision Date: 01/14/20	Archive Date: 01/14/20

DOCKET NO. 16-24 264
DATE: January 14, 2020

REMANDED

Entitlement to an initial rating in excess of 30 percent prior to June 4, 2019, and in excess of 50 percent as of June 4, 2019, for post-traumatic stress disorder is remanded.

REASONS FOR REMAND

The Veteran had active service from May 1986 to February 1993.

In an October 2019 submission, the Veteran canceled a scheduled Board hearing.  The Veteran's request for a hearing is deemed to be withdrawn.

1. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD) is remanded.

Although the Board of Veterans Appeals (Board) regrets the delay, a remand is necessary for further development. 

In a May 2019 Department of Veterans Affairs (VA) treatment note, the Veteran indicated that he was receiving treatment outside of VA for PTSD.  

These private treatment notes are not of record.  On remand, the Veteran should be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated him for PTSD. 

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).

Because of the incomplete record prior to the June 2019 examination, the examiner was unable to conduct a review of the complete and accurate history.  The Board therefore finds the examination deficient.  

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).  When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007).  Therefore, the Board finds that further VA evaluation is needed.

The matters are REMANDED for the following action:

1. The Veteran should be given an opportunity to identify any outstanding private treatment records relevant to the claim on appeal.  After obtaining any necessary authorization from the Veteran, all outstanding records, should be obtained. 

2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of service-connected PTSD.  The examiner should review the record and note such review in the examination report.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating PTSD under the rating criteria.  The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms.  To the extent possible, the examiner should identify any symptoms, and social and occupational impairment due to his PTSD alone.  The examiner should opine as to the levels of social and occupational impairment caused by PTSD and should describe the symptoms, and their frequency and severity, that results in those levels of impairment.  

 

 

Harvey P. Roberts

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	D. Duke, 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.