Decision Date: 07/31/95 Archive Date: 08/03/95 DOCKET NO. 93-16 646 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for post traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. R. Bucci, Associate Counsel INTRODUCTION The veteran served on active duty from June 1963 to February 1967. This appeal arises from a June 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. On appeal the veteran has raised the issues of entitlement to service connection for peripheral neuropathy, chloracne, and for a disorder manifested by numbness of the hands and feet. These issues, however, are not currently developed or certified for appellate review. Accordingly, they are referred to the RO for appropriate consideration. 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). A review of the veteran's service personnel records reveals that his military occupational specialty was air policeman with the 301st and 803d Combat Defense Squadrons. While he was awarded the Vietnam Service Medal and the Vietnam Campaign Medal, no awards or decorations for combat are shown. His Department of Defense Form 214 does not indicate that he was wounded. The veteran had nine months and fifteen days of foreign service. At his September 1992 personal hearing, however, the veteran testified that he currently suffers from PTSD as a result of his alleged combat experience in Vietnam. He stated that he spent his first ten days in Vietnam he spent loading caskets. He subsequently volunteered as a door gunner aboard a helicopter with the 101st Airborne. He further testified that he spent ten months in this assignment and was awarded the Air Medal and two Purple Hearts for his wounds. His helicopter allegedly was shot down on two occasions, and he witnessed the death of a crew member. The Board acknowledges that the RO attempted to obtain all the specifics from the veteran pertaining to his alleged stressors, but the record does not indicate that the RO has attempted to verify the veteran's claimed stressors through the offices of the U.S. Army and Joint Services Environmental Support Group (ESG). The United States Court of Veterans Appeals in West v. Brown, 7 Vet.App. 70 (1994), held that PTSD claims based on an allegation of a combat stressor require a determination whether or not the veteran actually engaged in combat. Accordingly, as 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). Lastly, the Board observes that post service the veteran was diagnosed on two occasions with PTSD due to his Vietnam experience. It appears from the record that the claims file was not available for review before the above diagnoses were rendered. Thus, these diagnoses were apparently based upon the unverified history as related by the veteran. Additionally, the examiner at the most current May 1992 VA psychiatric examination noted that he was not provided with the claims file and there was not enough data at the time of the exam to make a diagnosis of PTSD. As an adequate compensation examination requires that the examiner be afforded an opportunity to review and to consider all pertinent records "in order to assure a fully informed examination," Caffrey v. Brown, 6 Vet.App. 377, 381 (1994), the Board finds that the veteran was not provided a "thorough and contemporaneous medical examination." Green v. Derwinski, 1 Vet.App. 121, 123 (1991); Waddell v. Brown, 5 Vet.App. 454, 456 (1993). Accordingly, this case is REMANDED for the following action: 1. The RO should ask the veteran to provide the names and addresses of all medical care providers, private and/or VA, inpatient or outpatient, who have provided treatment since October 1992 for PTSD. After securing any necessary releases, the RO should obtain these records. 2. The RO should attempt to verify whether the veteran was awarded either the Air Medal and/or the Purple Heart. In this regard, the RO should again contact the National Personnel Records Center and request photocopies of any outstanding personnel and service medical records. 3. The veteran should again be asked to provide specific details about the stressful events he claims to have experienced in service. In this regard, the veteran should be asked to provide the precise dates and places of each claimed stressful event, as well as his unit assignment at the time of each claimed stressor. The veteran should further provide the full names and approximate dates of death of any comrades who were killed or wounded in action. The RO should also request that the veteran provide the full name and address of any comrade who witnessed the alleged traumas. The RO should then attempt to obtain a "buddy" statement from any identified person. The veteran is hereby informed that the United States Court of Veterans Appeals has held that requiring a claimant to provide this information to the VA does not represent an impossible or onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 4. Thereafter, the information provided by the appellant concerning the specific circumstances of the claimed stressors, and a copy of the veteran's service records must be sent to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, for verification of the stressors claimed by the veteran. 5. Following the receipt of the ESG's report, and the completion of any necessary development, the RO should prepare a report detailing the nature of any combat action, or stressful event, that has been 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. 6. 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 the veteran has PTSD 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. All opinions expressed must be accompanied by a complete rationale. 7. 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. In this respect the Board observes that the Court has held that a diagnosis of PTSD based on an examination which relies upon an unverified history is inadequate for rating purposes. West, 7 Vet.App. at 77. 8. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for PTSD. If the benefit sought on appeal is 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 provided. Thereafter, the case should be returned to the Board, if otherwise in order. By this REMAND, the Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action until he is otherwise notified. 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). - 2 -