93 Decision Citation: BVA 93-20280 Y93 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 85-29 600 ) DATE ) (RECONSIDERATION) ) ) THE ISSUES 1. Entitlement to service connection for schizophrenia. 2. Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The veteran; Dr. Eduardo T. Maaba ATTORNEY FOR THE BOARD T. H. Tousley, Associate Counsel INTRODUCTION The veteran had active military service from January 1956 to January 1960 and from July 1960 to March 1963. By a rating decision in March 1975, the Department of Veterans Affairs (VA) regional office (RO) in Manila, the Philippines, denied the veteran's claim for entitlement to service connection for a psychiatric disorder on the basis that the veteran's psychiatric disorder was a personality disorder for which service connection could not be granted. The veteran did not timely appeal this decision. Following denial of a reopened claim by the RO, the Board of Veterans' Appeals (Board) in March 1985 denied entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder. Thereafter, a new claim was again filed. The Board in January 1986 denied the veteran's claim for entitlement to service connection for an acquired psychiatric disorder essentially on the basis that there was no new and material evidence. Subsequently, in September 1992, the veteran's spouse filed on behalf of the veteran a Motion for Reconsideration of these decisions with the Board. Reconsideration of these decisions has been ordered by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991) and the case is now before an expanded Reconsideration Section of the Board. A final decision by the Reconsideration Section will replace the prior two decisions and will become the final decision of the Board. Based on the comments of the veteran's wife included in her statement dated in February 1985 and the veteran's substantive appeal dated in September 1985, the Board determines the veteran has specifically raised the issue of whether clear and unmistakable error was committed in the RO's rating decision in March 1975. The Board is required to address this issue which will be discussed in the remand section. Oppenheimer v. Derwinski, 1 Vet.App. 370, 372 (1991). REMAND The veteran served in the United States Navy from 1956 to 1963 with a six-month break in service during 1960. According to his service medical records, he served at Annapolis through 1957, on the U.S.S. Rich (DDE-820) during 1958 to early 1959, and the U.S.S. J. C. Breckinridge (AP-176) during the remainder of his first period of active duty. During his second period of active duty, he served on the U.S.S. General William Mitchell (AP-114) from 1960 to the spring of 1961, and the U.S.S. Shields (DD-596) from then until his hospitalization in October 1962 after reportedly stabbing another sailor with a knife. The initial diagnosis was psychotic-depressive reaction. The diagnosis on discharge in November 1962 from the hospitalization was schizoid personality disorder. He received an honorable discharge on the basis of hardship in March 1963. The veteran stated in his October 1974 application for disability compensation that he had received treatment since 1967 for variously claimed disorders from a Dr. Galang at the Municipal Health Center in San Fernando, Pampanga, the Philippines. The RO by a rating decision in March 1975 denied the veteran's claim for service connection for a psychiatric disorder on the basis that he had been diagnosed during service as having a personality disorder for which service connection could not be established. He did not timely appeal this decision. The veteran was hospitalized by the VA in October 1983. He submitted a claim for service connection for a psychiatric disorder at that time. The diagnosis on discharge was schizophrenia, paranoid type. In December 1983, Dr. Lorenzo A. Yuson reported the veteran saw him in August 1963 with complaints of psychiatric-type symptoms. The physician further stated he diagnosed schizophrenia, paranoid. Dr. Yuson reported in January 1984 that he also saw the veteran in December 1985. The veteran testified at the RO in June 1984 that when he served on "ship DDE 820 USS" (U.S.S. Rich), he believed in 1958, the ship was stranded for four days without food because of a broken propeller. A treating psychiatrist, Dr. Eduardo Maaba, submitted a report dated in July 1984 in which he opined the veteran had a post-traumatic stress disorder resulting from the "shipwreck" incident. The psychiatrist testified at the RO in October 1984 that he had been treating the veteran since July 1984. The psychiatrist added that his initial diagnostic impression had been that the veteran had a schizophrenic disorder, but he changed his diagnosis to post-traumatic stress disorder after further treatment and evaluation. He opined the veteran had a schizoid personality which had predisposed the veteran to develop post-traumatic stress disorder. The veteran and his wife in 1985 alleged the RO had committed clear and unmistakable error in its March 1975 rating decision. The veteran was hospitalized by the VA in 1985 and 1986. Both times, he was considered incompetent to handle his own funds. Based on the statements of the veteran, Dr. Yuson, and Dr. Maaba, the Board determines the veteran has submitted well-grounded claims for entitlement to service connection for schizophrenia and entitlement to service connection for post-traumatic stress disorder within the meaning of 38 U.S.C.A. § 5107(a) (West 1991), Murphy v. Derwinski, 1 Vet.App. at 81 (1990). Once a veteran has submitted well-grounded claims, the VA has a duty to assist him in development of facts pertinent to his claims. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). The duty to assist includes the duty to obtain all pertinent private medical records. Littke v. Derwinski, 1 Vet.App. 90, 92 (1990). The Board determines that Dr. Yuson's and Dr. Galang's records would be helpful in evaluating the veteran's claims, particularly in view of a diagnosis of schizophrenia within one year after separation from service. In addition, service connection for post-traumatic stress disorder "requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor." 38 C.F.R. § 3.304(f) (1993). It is reasonable to require some corroboration of the stressful event the veteran alleged happened to him during service. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). In this respect, the development of evidence by the RO regarding verification of a veteran's claimed stressor is governed by evidentiary requirements contained in the Department of Veterans Affairs Adjudication Procedure Manual, M21-1. If the claimed stressor is not combat related, as is in this case, a history of the stressor by the veteran is insufficient to establish service connection. Paragraph 7.46f, M21-1. It is necessary to develop the evidence when records available to the RO do not provide objective or supportive evidence of the claimed stressor. Paragraph 7.46f(2), M21-1. The veteran should provide specific details of the alleged event. Paragraph 7.46f(2)(a), M21-1. The Board notes the veteran's representative has requested that Navy records be checked to verify that the alleged stressor occurred. Moreover, the Board determines the claim of clear and unmistakable error is inextricably intertwined with the veteran's other claims. Harris v. Derwinski, 1 Vet.App. 180, 183 (1991). In order to obtain additional evidence, to verify the alleged inservice stressor, and to adjudicate the intertwined claim, the case is REMANDED to the RO for the following action: 1. After obtaining the necessary authorization, the RO should obtain from Dr. Lorenzo A. Yuson, copies of all available treatment records relating to the veteran since 1963. 2. After obtaining the necessary authorization, the RO should obtain from Dr. Galang, Municipal Health Center, San Fernando, Pampanga, the Philippines, copies of all treatment records relating to the veteran since 1967. 3. Pursuant to the requirments of Paragraph 7.46f(2)(a), the RO should obtain a detailed and specific statement from the veteran as to the "shipwreck" incident which has been identified as the stressor which precipitated the claimed post-traumatic stress disorder. The statment must be complete and adequate to permit verification. At minimum, it should include the name of the ship, the month and year of the incident, and a specific narrative of what happened, to the best of the veteran's recollection. Once this information is received, the RO should contact the Environmental Support Group (ESG) for confirmation of the incident in accordance with Paragraph 7.46f(2)(c) of M21-1. ESG should be requested to furnish actual copies of pertinent portions of the ship deck log if available. 4. An official psychiatric examination should be conducted to determine if the veteran has post- traumatic stress disorder. Since this diagnosis requires consideration of stressor information, the claims folder must be made available to the examiner. 5. The RO should adjudicate the claim of clear and unmistakable error in the rating decision of March 1975. 6. After completing the action requested, the RO should review the veteran's claims for entitlement to service connection for schizophrenia and post-traumatic stress disorder based on the entire evidence of record. If the benefit sought is not granted, the veteran and his representative should be furnished a supplemental statement of the case and they should be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development and to adjudicate an intertwined claim, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 WARREN W. RICE, JR. CHARLES E. HOGEBOOM ROBERT D. PHILIPP C. E. EDWARDS, M.D. BRUCE KANNEE NANCY R. ROBIN Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1992).