BVA9509161 DOCKET NO. 93-13 664 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Deborah W. Singleton, Counsel INTRODUCTION The veteran served on active duty from July 1966 to December 1968. This appeal arises from a rating decision dated in July 1992 by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. REMAND Service connection for post traumatic stress disorder (PTSD) 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) (1994). In this regard, the service records show that the veteran was an aircraft loadmaster with the 345th Troop Carrier Squadron, headquartered at Ching Chuan Kang Air Force Base at Taiwan in 1966 and 1967. In his December 1991 statement, the veteran reported that his duties with the 345th included periodic tours of combat flying duty in Vietnam as the loadmaster on C-130 aircraft transports. In connection with this duty, the veteran reported a 1967 incident in which his plane was hit by enemy ground fire. The aircraft pilot's name on that flight was identified as a Captain Burt. The veteran also reported an incident where he believed that the aircraft for which he was responsible for an airdrop was going to crash because the load (i.e., a 30 foot plank and 3 pallets) was stuck. The veteran related that if he had not reacted properly by pulling the emergency handle and releasing the load, the aircraft would have been dragged down by a "hung- up" load, killing everyone on board. He indicated that the pilot's name on that flight was a Major Pemberton. These same events were alleged by the veteran during a personal hearing before the RO in April 1992, together with testimony pertaining to claimed duties in assisting in the loading of wounded soldiers on board his aircraft on trips within Vietnam. The veteran’s personnel records reflect references to “austere and often hazardous conditions” associated with his Vietnam service. In light of this evidence, and because it does not appear that the RO has taken steps any to verify the veteran's alleged stressors by use of the United States Army and Environmental Support Group (ESG), the Board finds that further development is warranted. In this regard, the provisions of the VA ADJUDICATION PROCEDURE MANUAL M21-1 (MANUAL M21-1) pertaining to the adjudication of PTSD provide that, “where records available to the rating board do not provide objective or supportive evidence of the alleged inservice traumatic stressor, it is necessary to develop this evidence.” Manual M21-1, Part VI, 7.46(f)(2) (emphasis added). Accordingly, as the development outlined in MANUAL M21-1 includes providing the stressor information to the ESG in an attempt to verify the claimed stressors, such development is mandatory. The Board next observes that the veteran has been diagnosed with PTSD, on at least one occasion, while undergoing regular psychiatric treatment at the Contoocook Valley Counseling Center. That diagnosis, however, appears to have been based on a history which has yet to be verified. As an examination based on a questionable history is inadequate for rating purposes, West v. Brown, 7 Vet.App. 70, 78 (1994), it is necessary that the veteran be provided an examination where the examiner has an accurate history of the veteran's military service. Therefore, further development is warranted. Finally, the Board notes that while a history of the veteran's psychiatric care has been outlined in a September 1991 statement from the Contoocook Valley Counseling Center, none of these records of treatment dating back to 1982 have been secured and associated with the veteran's claims folder. Accordingly, these records should be obtained for the Board's review and the medical examiner's consideration. Murincsak v. Derwinski, 2 Vet.App. 363 (1992). Therefore, this case is REMANDED for the following action. 1. After obtaining any necessary authorization the RO should contact the Contoocook Valley Counseling Center in Henniker, New Hampshire, and request that they provide photocopies of records dating back to 1982, including any which may be on microfilm or microfiche. Any records received must be associated with the claims folder. 2. The RO should request that the veteran provide additional information containing specific details of the claimed stressful events during service. This information must include dates, places, detailed descriptions, units of service, duty assignments, as well as the names, ranks, units of assignment and any other identifying information concerning any other individual involved in any claimed stressful event. The veteran is hereby notified that the United States Court of Veterans Appeals has held that asking the veteran to provide underlying facts, i.e., the names, dates, and places of the claimed events, does not constitute either an impossible or onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 3. After obtaining the forgoing requested information, the RO should forward it to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, and attempt to verify the veteran’s claimed stressors. The ESG’s review is requested to include a search for any aircraft incident reports pertaining the incidents detailed by the veteran above, as well as a review of whether the duties of the veteran’s unit included shuttling wounded soldiers to medical facilities within Vietnam. Any information obtained is to be associated with the claims folder. 4. Following the receipt of the ESG’s report, and the completion of any additional development warranted or suggested by that office, the RO should prepare a report detailing the nature of any combat action, or inservice stressful event, verified by the ESG. If no combat or stressor has been verified, the RO should so state in their report. This report is then to be added to the claims folder. 5. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a psychiatrist who has not previously seen or treated the veteran. This examination is to be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of any psychiatric disorder which may be present. All indicated studies, including post-traumatic stress disorders sub scales, are to be performed. The claims file must be provided to and reviewed by the examiner prior to conducting this examination. In determining whether or not the veteran has PTSD due to an inservice stressor the examiner is hereby notified that only the verified history detailed in the reports provided by the ESG and/or the RO may be relied upon. If the examiner believes that PTSD is the appropriate diagnosis the examiner must specifically identify which stressor detailed in the ESG’s and/or the RO's report is responsible for that conclusion. Any and all opinions expressed must be accompanied by a complete rationale. 6. Following the completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination report to verify that any diagnosis of PTSD was based on the verified history provided by the ESG and/or the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the Court has held that a diagnosis of PTSD, related to service, which is based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 7. After undertaking any additional development deemed appropriate, the RO should readjudicate the issue of entitlement to service connection for PTSD. If the benefit requested on appeal is not granted to the veteran's satisfaction, the RO must issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. DEREK R. BROWN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. 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) (1994).