BVA9403373 DOCKET NO. 92-12 822 ) DATE ) ) ) THE ISSUES 1. Entitlement to service connection for schizophrenia. 2. Entitlement to an increased (compensable) disability evaluation for anxiety reaction. 3. Entitlement to an increased disability evaluation for residuals of a gunshot wound involving the left thigh, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Gottfried, Counsel INTRODUCTION The veteran served on active duty from August 1950 to August 1953. This case came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from rating decisions of the Department of Veterans Affairs (hereinafter VA), St. Petersburg, Florida, Regional Office (hereinafter RO). The RO determined in a rating decision of July 1991 that no new and material evidence had been presented to reopen a claim for entitlement to service connection for schizophrenia. The RO also denied increases in the noncompensable evaluation assigned for anxiety reaction and the 10 percent evaluation assigned for residuals of a gunshot wound involving the left thigh. The notice of disagreement was received in August 1991. The RO determined in a rating decision of October 1991 that evidence received in relation to the schizophrenia claim was new and material, but that the overall evidence of record did not support a grant of service connection for schizophrenia. A statement of the case was issued in October 1991. A substantive appeal was received from the veteran in November 1991. The RO determined in a rating decision of January 1992 that there was no new and material evicence to reopen the schizophrenia claim. A supplemental statement of the case was issued in January 1992. The veteran testified at a personal hearing in the RO in March 1992. A VA hearing officer continued to deny the claims in April 1992. A supplemental statement of the case was issued in May 1992. The case was received and docketed at the Board in July 1992. The veteran has been represented throughout his appeal by Disabled American Veterans. That organization submitted additional written argument to the Board in November 1992. Although the certified issues from the RO include the issue of whether new and material evidence has been presented to reopen a claim for service-connection for schizophrenia, the Board has found that the RO reopened the claim in the rating decision of October 1991, and that the statement of the case adequately addressed the issue on a de novo basis. Therefore, the Board has determined that the proper issue before the Board for appellate review is entitlement to service connection for schizophrenia. REMAND The veteran has contended on appeal that he is unable to maintain gainful employment as a result of his service-connected anxiety reaction. He made specific reference to this in his substantive appeal of November 1991. He has clearly raised the issue of entitlement to a total rating based on individual unemployability due to service-connected disability. This issue is inextricably intertwined with the increased rating issue pertaining to anxiety reaction. Harris v. Derwinski, 1 Vet.App. 180 (1991). This issue needs to be addressed in the RO. The VA examiner opined in June 1991 that the veteran's schizophrenia was a maturation of the service-connected anxiety reaction. The veteran underwent a VA compensation and pension examination at that time. It appears that the examiners may not have had the veteran's medical records before him for review to assist in the examination and in the rendering of the medical opinion. This is a requirement of the VA's Physician's Guide for Disability Evaluation Examinations. Further, the examination does not appear to have been very extensive, and apparently relied heavily upon history supplied by the veteran. Medical opinion obtained in prior years was to the effect that no relationship existed between the service-connected anxiety reaction and the veteran's schizophrenia. The Board believes that the veteran should be examined by a board of two VA psychiatrists, and that all of his treatment records should be made available for their review. The latest VA rating examinations were done in 1991. The VA treatment records are not dated beyond December 1991. The Board believes that up-to-date treatment records should be secured, and special examinations should be scheduled in relation to the appellate issues. The veteran has reported that he is receiving Social Security disability benefits. The records upon which the Social Security disability determination was made are not of record. These records should be obtained as they may be useful in the adjudication of the issues. Masors v. Derwinski, 2 Vet.App. 181 (1992). The service medical records included with the claims folder appear to be incomplete. Included with the claims folder are a few clinical records and examination reports. Additional records may be useful in the adjudication of the issues. This matter needs to be addressed in the RO. The Board is mindful of the VA's duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Veterans Appeals (the Court) has held that the duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining records from any source and obtaining adequate VA examinations. Littke v. Derwinski, 1 Vet.App. 90 (1990). This duty includes additional VA examination by a specialist, when recommended. Hyder v. Derwinski, 1 Vet.App. 221 (1991). Under the circumstances of this case, the Board believes further development is needed. The case is REMANDED to the RO for the following: 1. Efforts should be made in accordance with VA Manual M21-1 to obtain all available service medical records or copies thereof. All records obtained should be associated with the claims folder. 2. The veteran should be contacted to clarify whether he wishes to file a claim for a total rating based on individual unemployability. If so, an employment history should be secured from the veteran. All appropriate development should be completed. 3. Appropriate measures should be taken to obtain copies of all of the medical records that formed the basis for the veteran's total disability determination before the Social Security Administration. If necessary, contact should be made with the veteran or his representative for further information. Also, if necessary, the veteran should be asked to sign and submit an appropriate form authorizing release of the records to the VA. Copies of all records obtained should be associated with the claims folder. 4. The veteran should be contacted in an attempt to determine all sources of treatment for the left leg gunshot wound disorder or psychiatric disorders since December 1991. If necessary, the veteran should be asked to sign and submit appropriate forms giving his consent for release of the records to the VA. Thereafter, copies of all treatment records, to include records of any treatment from the VA, should be secured. All records not already associated with the claims folder should be associated with the folder. 5. After all of the development requested above is completed, the veteran should be scheduled for a special orthopedic examination to determine the nature and extent of the residuals of the wound to his left thigh. The examination should include all indicated tests and studies, to include X-rays. The claims folder should be made available to the examiner. The examiner should be requested to review the record and interview the veteran in order to compile and report a complete history to assist in the examination. The examiner should be requested to comment as to any abnormalities found, to include any functional deficits that may be present as a result of pain or other factors. 6. The veteran should also be scheduled for an examination by a board of two VA psychiatrists with a view towards determining the etiology, nature, and severity of all psychiatric disorders present, to include the service- connected anxiety reaction, and with the specific goal of determining whether or not the veteran has schizophrenia or any other psychiatric disorder that has been caused by the anxiety reaction or is a maturation of the anxiety reaction. The examination should include a psychological evaluation, if indicated. The claims folder should be made available to the examiners. They should be requested to review the record prior to their examinations of the veteran so that they can make a longitudinal review of the available evidence to assist in their examination of the veteran and in the rendering of an opinion. When all of the development is completed, the RO should review the increased rating, service connection, and unemployability issues. The issues should be reviewed in accordance with all current legal authority, to include appropriate laws and regulations. The increased rating issue should be reviewed in relation to Schafrath v. Derwinski, 1 Vet.App. 589 (1991) which discusses a need to review the veteran's medical history and relevant sections of 38 C.F.R. Parts 3 and 4 in increased rating cases, to include 38 C.F.R. § 4.40 which relates to functional deficits that may be present as a result of pain. Also, the unemployability issue should be reviewed in relation to relevant decisions of the Court, to include Moore v. Derwinski, 1 Vet.App. 356, 359 (1991) and Hatlestad v. Derwinski, 1 Vet.App. 164, 168 (1991). After the issues are reviewed, the veteran and his representative should be furnished a supplemental statement of the case that includes a recitation of all applicable laws and regulations, and a full discussion of the reasons for all action taken. They should then be provided an adequate opportunity to respond before the record is returned to the Board for further appellate review. The purpose of this remand is to procure additional clarifying information and to ensure that all of the issues are fully addressed. No action is required of the veteran until he receives further notice. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 WILLIAM J. REDDY HARRY M. McALLISTER, M.D. M. SABULSKY 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) (1993).