Citation Nr: 21007098
Decision Date: 02/08/21	Archive Date: 02/08/21

DOCKET NO. 19-12 030
DATE: February 8, 2021

REMANDED

Entitlement to a disability rating higher than 30 percent for service-connected posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from February 1967 to October 1968. 

On his March 2019 VA Form 9, Substantive Appeal to the Board, the Veteran requested a hearing before a Veterans Law Judge of the Board, but his representative subsequently withdrew that request in writing in December 2020. 38 C.F.R. § 20.704(e).

This claim must be further developed because a preliminary review of the file shows the Veteran last had a VA compensation examination to determine the severity of his service-connected PTSD in June 2018, so almost 3 years ago. And, while the mere passage of time is not a basis for requiring a new examination, the evidence suggests this disability has worsened appreciably since that examination. See March 2019 VA Form 9, Substantive Appeal (Veteran reports suffering from short-term memory loss, impaired judgment, extreme disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships); April 2019 K.F. correspondence; June 2019 Dr. M.M. correspondence; June 2019 Dr. M.J. correspondence; September 2020 Veteran Representative Correspondence. Therefore, a new VA examination is needed reassessing the severity of this service-connected disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Any outstanding treatment records also should be requested since they, too, may address the current severity of this disability.

Accordingly, this claim is REMANDED for the following action:

1. Contact the Veteran and request authorization to obtain any outstanding records pertinent to his claim, including any private treatment records following proper VA procedures (38 C.F.R. § 3.159(c)). Appropriately notify him and his representative if unable to obtain records identified (38 C.F.R. § 3.159(e)).

2. After receiving all additional treatment or other records, have the Veteran reexamined to reassess the severity of his service-connected PTSD. A copy of this remand and all relevant medical and other records must be made available to the examiner. The examiner must review the pertinent evidence, including the Veteran’s lay assertions, and undertake all necessary mental status testing and evaluation to ensure all applicable rating criteria are addressed.

In reassessing the severity of the Veteran’s PTSD, the examiner is asked to address the functional impact of this service-connected disability (occupationally and socially), so including  in terms of the extent it impairs the Veteran’s ability to meet the demands of a job, whether sedentary or physically demanding. 

 

It is essential the examiner provide rationale for his/her opinions, preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. 

 

KEITH W. ALLEN

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	C. Mukherjee

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.