Citation NR: 9619151 Decision Date: 07/09/96 Archive Date: 07/22/96 DOCKET NO. 94-11 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for peptic ulcer disease. 3. Entitlement to service connection for a variously diagnosed chronic acquired psychiatric disorder including post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran performed creditable active duty service from September 1968 to September 1970. This appeal arose from an August 1988 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The RO denied entitlement to service connection for hypertension, peptic ulcer disease, and a variously diagnosed chronic acquired psychiatric disorder including post-traumatic stress disorder. Following the veteran’s relocation, the case was forwarded to the Board of Veterans’ Appeals (Board) by the Chicago, Illinois RO for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he suffers from hypertension and peptic ulcer disease as the result of his active service, thereby warranting entitlement to grants of service connection. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1995), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the claims for service connection for hypertension and peptic ulcer disease are not well grounded. FINDINGS OF FACT 1. The claim of entitlement to service connection for hypertension is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The claim of entitlement to service connection for peptic ulcer disease is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for hypertension is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. The claim of entitlement to service connection for peptic ulcer disease is not well grounded. 38 U.S.C.A. § 5107. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the applicable law, a veteran is entitled to service connection for a disease or injury incurred in or aggravated while in service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1995). If not shown during service, service connection may be granted for hypertension and peptic ulcer disease if shown disabling to a compensable degree during the first post service year. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1995). A threshold question to be answered is whether the veteran has presented well grounded claims; that is, claims that are plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Although the claim need not be conclusive, it must be accompanied by supporting evidence. An allegation alone is not sufficient. Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). Three discrete types of evidence must be present in order for a veteran’s claim for benefits to be well grounded: (1) There must be competent evidence of a current disability, usually shown by a medical diagnosis. See Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet.App. 141, 144 (1992); (2) There must be competent evidence of incurrence or aggravation of a disease or injury in service. This element may be shown by lay or medical evidence. See Layno v. Brown, 6 Vet.App. 465, 469 (1994); Cartwright v. Derwinski, 2 Vet.App. 24, 25 (1991); and (3) There must be competent evidence of a nexus between the in- service injury or disease and the current disability. Such a nexus must be shown by medical evidence. See Lathan v. Brown, 7 Vet.App. 359, 365 (1995); Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). In determining whether a claim is well grounded, the Board is required to presume the truthfulness of evidence. Robinette v. Brown, 8 Vet.App. 69, 77-8 (1995); King v. Brown, 5 Vet.App. 19, 21 (1993). In the veteran’s case the above discussed elements have not been satisfied. In this regard the Board notes that the service medical records are negative for any evidence of either hypertension or peptic ulcer disease. Correspondence from a private physician on file dated in June 1988 contains diagnoses including hypertension and peptic ulcer disease by history. It was noted the veteran reported having been diagnosed with peptic ulcer disease in 1982, and a review of hospital records note a diagnosis of rule out peptic ulcer disease in 1983. Peptic ulcer disease is noted in later dated medical documentation of record. The veteran has alleged that his post service diagnosed hypertension and peptic ulcer disease originated coincident with his active service. Significantly, however, he has presented no competent medical evidence linking such disorders to his period of active service. As it is the province of trained health professionals to enter conclusions which require medical opinions as to causation, Grivois v. Brown, 6 Vet.App. 136 (1994), the veteran’s lay opinion is an insufficient basis to find his claims well grounded. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Accordingly, as well grounded claims must be supported by evidence, not merely allegations, Tirpak, the veteran’s claims for service connection for hypertension and peptic ulcer disease must be denied as not well grounded. The Board recognizes that the appellant’s claims have been disposed of in a manner different from that utilized by the RO. The Board therefore considered whether the claimant has been given adequate notice to respond, and if not, whether he has been prejudiced thereby. Bernard v. Brown, 4 Vet.App. 384 (1993). In light of the implausibility of the appellant’s claims and the failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his claims for service connection for hypertension and peptic ulcer disease. As the foregoing explains the need for competent evidence linking a current disorder to the veteran’s creditable active duty service, the Board views the discussion set forth above as sufficient to inform the veteran of the elements necessary to complete his application for claims for service connection for hypertension and peptic ulcer disease. 38 U.S.C.A. § 5103(a) (West 1991); see Robinette, 8 Vet.App. at 77-8; see also Isenhart v. Derwinski, 3 Vet.App. 177, 179-80 (1992) (VA has a duty to advise claimant of evidence required to complete application). ORDER The veteran not having submitted evidence of a well grounded claim of entitlement to service connection for hypertension, the claim is denied. The veteran not having submitted evidence of a well grounded claim of entitlement to service connection for peptic ulcer disease, the claim is denied. REMAND Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s). 38 C.F.R. § 3.304(f) (1995). In this regard, the veteran was trained as a truck driver and clerk, and served a tour with the United States Army in Vietnam. His decorations include a Vietnam Campaign Medal and a Vietnam Service Medal. Unfortunately, the claims file does not contain a detailed stressor statement from the veteran; however the veteran does provide accounts of service stressors in the clinical setting as shown by medical documentation of record. The information provided by the veteran is general, and couched in vague terms. The RO has not referred any of the information on file 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 stressor information provided by the veteran may not be sufficiently complete to permit the ESG to verify any of the stressor information now in the claims file. 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 in-service 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 the veteran has been diagnosed with post-traumatic stress disorder by VA and non-VA medical health professionals. 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. 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); 38 C.F.R. § 3.103(a) (1995), the Board will not decide the issue of entitlement to service connection for a variously diagnosed chronic acquired psychiatric disorder including post-traumatic stress disorder pending a remand of the case to the RO for further development as follows: 1. The RO should request from the veteran 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, places, detailed descriptions, units of service, duty assignments, as well as the names, 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 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, does not constitute an impossible or an onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 2. The RO should attempt to secure the veteran’s “201 file” for the period of service from September 1968 to September 1970 from the National Personnel Records Center. 3. After obtaining the foregoing requested information, 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 (ESG), 7798 Cissna Road, Springfield, Virginia 22150, in an attempt to verify any claimed stressor. Any information obtained is to be associated with the claims file. The RO must conduct this development even if the veteran fails to provide the stressor statement outlined in paragraph one, supra. In the event that the veteran fails to respond, the RO must ask the ESG to attempt to verify the claimed stressor based on the limited information already in the claims file. 4. Following receipt of the ESG’s report, and the completion of any additional development warranted or suggested by that agency, the RO should prepare a report detailing the nature of any combat action, or in-service stressful event, verified by the ESG. If no combat stressor has been verified, the RO should so state in its 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 psychiatric examination by a board of two VA psychiatrists who have not previously seen or treated him. The examination is to be conducted in accordance with the diagnostic procedures outlined in the VA Physician’s Guide for Disability Evaluation Examinations. All indicated studies including post-traumatic stress disorder sub scales are to be performed. The claims file must be made available to and reviewed by the examiners prior to conduction and completion of the examinations. In determining whether or not the veteran has post-traumatic stress disorder due to an in-service 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 reports 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. 6. 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 the 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. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for a variously diagnosed chronic acquired psychiatric disorder including post-traumatic stress disorder. If the benefit requested 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 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, 741 (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. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West Supp. 1995), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a 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) (1995). - 2 -