BVA9510836 DOCKET NO. 93-08 643 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to service connection for an eye disorder. 3. Entitlement to an increased evaluation for postoperative removal of the left lower 12th rib for drainage of a liver abscess, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from November 1950 to March 1956. This appeal arose from July and December 1991 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The RO denied entitlement to service connection for post-traumatic stress disorder and an eye disorder, as well as entitlement to an increased evaluation for postoperative removal of the left lower 12th rib for drainage of a liver abscess. On appeal the veteran appears to raise the claim of entitlement to a separate rating for a liver disorder, to include liver dysfunction, separate and distinct from the current rating assigned for postoperative residuals of a rib removal. This issue, however, is not currently developed or certified for appellate review. Accordingly, it is referred to the RO for appropriate action. REMAND Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the disorder, credible supporting evidence that the claimed inservice stressor(s) 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 veteran served as a combat engineer with the United States Army, and served a tour of duty in Korea. His decorations include the Korean Service Medal with three bronze service stars, and the United Nations Service Medal. The appellant is not shown to have been awarded the Combat Infantryman’s Badge, Purple Heart Medal, or other decoration reflective of combat activity. He has, however, identified by name, Spurgeon Foster, a high school friend whose death he witnessed in combat action, and has described other combat activity such as enemy fire. Unfortunately, the stressor statement provided by the veteran on file is not sufficiently detailed as it perhaps could be. The Board further observes that the stressor information which the veteran has supplied to the RO has not been referred to the United States Army and Joint Services Environmental Support Group (ESG) in an attempt to verify the claimed stressors. In this respect, the Board acknowledges that the information provided by the veteran probably is not as complete as the ESG will need to verify the existence of the veteran's claimed stressor. Nevertheless, the provisions of the VA Adjudication Procedure Manual M21-1 (Manual M21-1) pertaining to the adjudication of post-traumatic stress disorder 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 information submitted by the veteran to the ESG, such development is mandatory. The Board observes that a board of VA psychiatrists determined that the veteran was suffering from post-traumatic stress disorder as the result of their examination conducted in March 1991. Diagnoses of post-traumatic stress disorder are also contained in the VA mental health clinic records on file. An examination based on a questionable history, however, is inadequate for rating purposes, West v. Brown, 7 Vet.App. 70, 77-8 (1994). Thus, it is necessary that the veteran be provided an examination where the examiner has the accurate history of the appellant’s military service. Furthermore, the Board observes that the claimant has been receiving treatment at the VA Medical Center in Montgomery, Alabama, presumably for psychiatric symptomatology for the past thirty years. Only records dated in 1991 were associated with the claims file in connection with the current appeal. Hence, further development is warranted. Further development is also warranted as the veteran’s post operative residuals of a rib fracture removal due to a liver abscess have not examined for compensation purposes in several decades. Therefore, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), this case is REMANDED to the RO for the following development: 1. The RO should request and associate with the claims file copies of the complete records pertaining to the veteran's treatment for the past thirty years at the VA Medical Center in Montgomery, Alabama. 2. The RO should contact the veteran and request that he identify any and all non- VA health care providers who have treated him for post-traumatic stress disorder or psychiatric symptomatology in general since service. After obtaining any necessary authorization, the RO should request and associate with the claims file copies of the complete records pertaining to the veteran's treatment from the sources identified. 3. The RO should request from the appellant a statement containing as much detail as possible regarding any and all stressful events to which he was exposed in service. He should be asked to provide specific details of the claimed stressful events to the best of his ability. The veteran’s statement should include dates (including the date or approximate date of Spurgeon Foster’s death), places, detailed descriptions, units of service, duty assignments, as well as the names, ranks, units of assignment and any other identifying information concerning other individuals involved in the events. In this respect, the Board takes this opportunity to inform the veteran that the United States Court of Veterans Appeals (Court) has held that asking the veteran to provide the underlying facts, i.e., the names of individuals involved, the dates, and the places where the claimed events occurred, not to constitute an impossible or an onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 4. After obtaining the forgoing requested information from the veteran, the RO should forward it together with copies of the claimant's service personnel records, and a copy of his record of service (DD-214) to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, in attempt to verify any claimed stressor, including specifically the claimed stressor involving the death of Spurgeon Foster. Any information obtained is to be associated with the claims file. 5. Following 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 stressor has been verified, the RO should so state in their report. This report is then to be added to the claims folder. 6. Then, and only then, should the RO schedule the appellant for a psychiatric examination by a board of two VA psychiatrists who have not previously seen or treated him. This examination is to be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of any psychiatric disorder(s) which may be present. All indicated studies, including post-traumatic stress disorder sub scales, are to be performed. The claims file must be provided to and reviewed by the examiners prior to concluding their examinations. In determining whether or not the veteran has post-traumatic stress disorder due to an inservice stressor the examiners are 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 examiners believe that post-traumatic stress disorder is the appropriate diagnosis they must specifically identify which stressor(s) detailed in the ESG's and/or the RO's report is (are) responsible for that conclusion. Any and all opinions expressed must be accompanied by a complete rationale. The examiners must assign a Global Assessment of Functioning Score which is consistent with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, and explain what the assigned score means. 7. Following 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 post- traumatic stress disorder was based on the verified history provided by the ESG and/or RO. If the examiners relied upon a history which was 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 post-traumatic stress disorder, related to service, based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 8. The RO should schedule the veteran for an appropriate medical examination to determine the nature and extent of severity of his postoperative residuals of a removal of the left lower 12th rib for drainage of a liver abscess. All indicated studies are to be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. 9. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issues of entitlement to service connection for post-traumatic stress disorder and entitlement to an increased evaluation for postoperative residuals of a removal of the left lower 12th rib for drainage of a liver abscess. The issue of entitlement to service connection for an eye disorder is deferred. If the benefits sought on appeal are not granted to the veteran's satisfaction, the RO should 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).