Citation Nr: 21041134
Decision Date: 07/08/21	Archive Date: 07/08/21

DOCKET NO. 17-04 802A
DATE: July 8, 2021

REMANDED

Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) and residuals of a traumatic brain injury (TBI) is remanded. 

Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded.

REASONS FOR REMAND

The Veteran served in the United States Army from June 1984 to March 1990.

This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).  

The issue regarding an increased rating for PTSD with residuals of a TBI was remanded by the Board in January 2019 for further development. 

As discussed in the January 2019 remand, the record indicates that the Veteran has been receiving care from a private psychologist, Dr. K.U., for his PTSD since November 7, 2011.  Although an attempt to obtain information from the Veteran was made by the Agency of Original Jurisdiction (AOJ) in September 2019, no records have been obtained.  On remand, another attempt should be made to obtain these records as they may prove relevant to the claims on appeal. 

Further, the Veteran was last afforded a VA psychiatric examination in September 2016, more than 4 years ago.  See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous").  The record also shows that the Veteran was convicted for a felony in 2018.  The Board finds that a new VA examination is needed to assess the current severity of the Veteran's PTSD and TBI residuals in order for the Board to make a fully informed decision, to include the circumstances surrounding his incarceration.    

The matters are REMANDED for the following actions:

1. Make an additional attempt to contact the Veteran and request properly executed VA Form 21-4142, Authorization and Consent to Release Information, to the Department of Veterans Affairs, for any private care providers who have treated him for PTSD, to include           Dr. K.U. 

If the Veteran returns completed release(s) of information, the AOJ should request the records and associate them with the claims file.  All efforts to obtain these records should be memorialized in the claims file, and appropriate notice should be provided to the Veteran if the records cannot be obtained.

2. Obtain all outstanding VA treatment records since July 10, 2019.

3. Schedule the Veteran for a VA examination to ascertain the current severity of his service-connected PTSD and residuals of a TBI.

**The examiner should address the occupational impairment/limitations due to his PTSD and TBI disability.

4. Then, readjudicate the claims on appeal.

 

 

L. Chu

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	R. Casadei, 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.