Citation Nr: 22018916
Decision Date: 03/30/22	Archive Date: 03/30/22

DOCKET NO. 18-29 851
DATE: March 30, 2022

REMANDED

Entitlement to a disability rating in excess of 70 percent for service-connected post-traumatic stress disorder (PTSD) is remanded.

INTRODUCTION

The Veteran served honorably on active duty in the United States Army during the Vietnam Era, from May 1966 to May 1968.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2016 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii.

The Veteran testified under oath before the undersigned Veterans Law Judge (VLJ) at a hearing conducted in April 2021.  

When this matter came before the Board previously in April 2021 it was remanded for additional development, particularly, to afford the Veteran a contemporaneous VA examination assessing the current nature and severity of his PTSD.  

REASONS FOR REMAND

Entitlement to a disability rating in excess of 70 percent for service-connected PTSD is remanded.

In May 2018, a PTSD Disability Benefits Questionnaire (DBQ) was completed by the Veteran's private treating psychologist, A.G., Ph.D.  According to Dr. A.G., the Veteran's level of occupational and social impairment is best summarized as total.  A VA treatment note dated October 2019 indicates the Veteran was seeing Dr. A.G. "for individual psychotherapy but only sporadically and has not seen him in 6 [months]."  During the April 2021 hearing, the Veteran's representative indicated Dr. A.G. had been treating the Veteran "since 2017."  The Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940) dated April 2021 also reflects ongoing treatment with Dr. A.G.

Upon review, the Board observes treatment records from Dr. A.G. have not been associated with the claims file.  As these potentially relevant records have not been requested, remand is again required to allow VA to satisfy its duty to assist by obtaining the Veteran's authorization and requesting these records.  

Accordingly, this matter is REMANDED for the actions:

1.  Send the Veteran and his representative a letter enclosing VA Form 21-4142 to complete and return authorizing VA to obtain all private (non-VA) medical treatment records including, but not limited to, those by Dr. A.G.  Make at least two attempts to obtain records from all identified sources.  If any such records are unavailable, the Veteran and his representative must be notified and afforded an opportunity to submit any copies in their possession.

2.   Obtain the Veteran's updated VA treatment records since July 2021 and associate them with the claims file accordingly.

3.  Following completion of items 1, 2, and 3 above, obtain an addendum VA medical opinion from an examiner possessing the necessary expertise to fully assess the nature and severity of the Veteran's service-connected PTSD, considering all pertinent lay and medical evidence of record including any such evidence associated with the claims file since the prior July 2021 examination.

If the examiner determines that an examination of the Veteran is needed to provide the requested opinion, such examination must be scheduled and may be conducted via telehealth interview accompanied by a review of the claims file.

 

 

STEVEN D. REISS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	E. Worsham, Attorney Advisor

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.