Citation Nr: 21031180
Decision Date: 05/20/21	Archive Date: 05/20/21

DOCKET NO. 20-09 723
DATE: May 20, 2021

REMANDED

Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from May 2007 to May 2008, December 2009 to May 2010, and February 2011 to March 2012.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 

In May 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge.

Entitlement to an initial disability rating in excess of 50 percent for PTSD is remanded.

The Veteran's most recent VA examination for his PTSD occurred in October 2017. Since that time, he has indicated that his disability has worsened. See May 2021 Board hearing.  Because it has been over three years since the last VA examination, remand for a contemporaneous examination is required to assess the current severity of his service-connected disability. See Green v. Derwinski, 1 Vet. App. 121 (1991); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997).

Also, the record suggests that the medical evidence associated with the record is incomplete. The most recent VA treatment records in the claim file are from June 2014, nearly seven years ago.  During his May 2021 Board hearing, the Veteran testified that he continued to receive VA treatment and that his last treatment was in February 2020.  As more recent VA records are likely to contain pertinent information, and because VA treatment records are constructively of record, they must be obtained prior to adjudication of this claim.

The matter is REMANDED for the following action:	

1. Obtain copies of VA treatment records from June 2014 to the present.

2. Obtain, if possible, records of relevant private evaluations and treatment the Veteran has received. The Veteran must assist in the matter by identifying his private healthcare providers and by submitting releases for VA to obtain any private records identified.

3. After the development in the first instruction is completed, arrange for the Veteran to be examined (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by a psychiatrist or psychologist to assess the current severity of his service-connected PTSD. The Veteran's record must be reviewed by the examiner in conjunction with the examination. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following:

(a) Describe the presence or absence of each symptom listed in the criteria for ratings above 50 percent (and also note any symptoms of similar gravity found that are not listed, to include the degree of severity of each and impact on function).

(b) Specifically comment on the overall impact the service-connected PTSD has on occupational and daily activity functioning.

4. If upon completion of the above action the issue remains denied, the case should be returned to the Board after compliance with appellate procedures.

 

 

E. I. VELEZ

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Matta, 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.