BVA9505824 DOCKET NO. 93-14 885 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUE Entitlement to an increased rating for anxiety neurosis with conversion and depressive features manifested by headaches, currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Maine Division of Veterans Services WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Richard E. Coppola, Associate Counsel INTRODUCTION The veteran served on active duty from March 1967 to December 1970. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Togus, Maine, Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to a rating in excess of 50 percent for the veteran's service-connected psychiatric disorder. In March 1993, the RO denied entitlement to a total rating for individual unemployability by reason of service-connected disability. The RO notified the veteran of that decision by letter dated April 13, 1993. He did not appeal that decision. REMAND The case was received at the Board in July 1993. In September 1993, additional evidence was added to the records assembled for appellate review. This additional evidence consists of an August 1993 report of VA examination and evaluation. This evidence is new and has not previously been considered by the RO. The veteran has not waived his right to have this new evidence initially considered by the RO. See 38 C.F.R. § 20.1304(c) (1994). The evidence discloses that the veteran was hospitalized for four days in January 1992 as a result of increased symptoms associated with his psychiatric disability. The hospital report indicates that the veteran's symptoms had quite clearly improved by the time of discharge. The veteran reported receiving workers compensation in connection with low back problems, and the report indicates that the veteran was unemployable due to his back injury. On VA examination in February 1992, the psychiatrist opined that the veteran's social impairment was mild and sometimes mild-to-moderate. The psychiatrist opined that the veteran's industrial impairment was moderate. In March 1992, a VA physician opined that the veteran's current functioning was seriously affected by depression, anxiety and emotional instability. The evidence also includes VA outpatient treatment records which are dated from January 1991 to February 1993. These records show complaints of chronic headache symptoms which were not improved significantly with medication. Some of the more recent outpatient notations in August, September and November 1992 indicate that the veteran was stable, while others indicate increased symptoms. The most recent notation, dated in January 1993, reveals an impression of slight deterioration of social function. At a personal hearing, the veteran testified that his disability had increased in severity because he was no longer able to cope with the symptoms. Transcript, p. 5 (Jan. 1993). He also testified that he was evaluated in December 1992 by a VA neurologist, Dr. Sanderson, who was working with his treating physicians in order to alleviate the headache symptoms. Tr., at p. 6. The evidence is not clear as to the current symptoms associated with the veteran's service-connected psychiatric disorder. In The Board's judgment, a current VA psychiatric examination would be helpful in connection with this appeal to determine the nature and severity of his disability. Under the circumstances, the Board finds that additional development of the evidence is necessary. Accordingly, the case is REMANDED for the following actions: 1. The veteran should identify the names and addresses of any medical care providers, VA or otherwise, who have treated him for his service-connected disability since February 1993. After obtaining any needed authorization from the veteran, the RO should request copies of all such records for inclusion in the claims folder. 2. The veteran should be afforded a psychiatric examination in order to determine the current manifestations and severity of his service-connected psychiatric disability. The examination should be conducted in accordance with VA's Physician's Guide for Disability Evaluation Examinations, and should include any indicated testing, including appropriate psychological studies. The examiner should elicit from the veteran a detailed work history, as well as data concerning his education, medical, and social history. The examiner should report the veteran's complaints, provide a description of pertinent symptoms, subject and objective, and integrate current findings and diagnoses with earlier data. The examiner should also discuss the degree of impairment attributable to the psychiatric disorder and provide a Global Assessment of Functioning Scale code along with the associated descriptive phrase. The claims folder must be made available to the physician prior to the examination. 3. When the above development has been completed, the case should be reviewed by the RO. The rating decision should reflect consideration of all potentially applicable criteria, to include consideration of the applicability of 38 C.F.R. § 3.321(b)(1). If the decision remains adverse to the veteran in any way, he and his representative should be furnished with a supplemental statement of the case which summarizes the pertinent evidence and reflects detailed reasons and bases for the decision. They should then be afforded the applicable time period to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. CHARLES E. HOGEBOOM 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 deter- mination. 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).