BVA9505796 DOCKET NO. 93-15 786 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of malaria. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD Richard E. Coppola, Associate Counsel INTRODUCTION The veteran had active service from December 1942 to December 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of February 1993 from the Muskogee, Oklahoma, Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for PTSD, Bell's palsy and residuals of malaria. In the notice of disagreement, the veteran expressed dissatisfaction with the denials for PTSD and residuals of malaria. He framed his disagreement in terms of the VA's denial of "Malaria{Jungle Rot." The statement of the case listed the issues as entitlement to service connection for PTSD, Bell's palsy and residuals of malaria. In April 1993, the RO denied service connection for jungle rot. It does not appear from the claims folder that the RO notified the veteran of that determination. In the substantive appeal, the veteran referred only to the issue of service connection for PTSD. The local representative listed the issues on appeal as entitlement to service connection for PTSD, Bell's palsy and residuals of malaria, and indicated that the latter issues should be decided on the evidence of record. The certification of appeal lists service connection for PTSD as the only issue on appeal. Based on the evidence of record, the Board finds that the issues properly developed on appeal are service connection for PTSD and residuals of malaria. The RO should issue the veteran a notice of denial of service connection for jungle rot. The RO should then issue a statement of the case for the issues that have been appealed. Of course, the RO may contact the veteran to clarify which issues he intends for appellate review. REMAND The veteran seeks service connection for PTSD which he claims was caused by combat exposure during active duty in World War II. In his application for disability compensation, the veteran reported treatment for "battle fatigue" or PTSD in 1943 and 1944 at Luzon. Unfortunately, it appears that the veteran's service medical records were destroyed by fire in 1973. The veteran submitted a copy of his DD Form 214 which reveals that he was awarded the Bronze Star Medal. It lists his military occupational specialty as radio operator. It is unclear from the record whether he received that medal for heroism against the enemy or for meritorious achievement of service. An attempt should be made to verify the basis for the veteran's Bronze Star Medal through examination of the citation or award orders. At the January 1993 VA examination, the veteran stated that he participated in several different invasions and landings in the Asiatic-Pacific Theater. He stated that he participated in intense combat with the enemy most of the time and most of his fellow squad members were killed in action. The physician reported that there were symptoms indicative of PTSD but concluded that the veteran did not present evidence for PTSD based on that examination. The physician's diagnoses were generalized anxiety disorder and dysthymia. The physician opined that the veteran had a chronic anxiety disorder since being in the military. In his notice of disagreement, the veteran stated that he was confused about the issue of PTSD during that examination and requested another interview. The veteran has not been afforded an adequate opportunity to relate specific stressors that occurred during service in support of his claim. Additionally, the veteran submitted a January 1993 statement of Fred C. LeMaster, D.O., which notes the veteran had been receiving medical care since 1958 and has received medication over the last several years for increasing anxiety/depression. Actual treatment records associated with such are have not been requested or obtained. The veteran argues that he has taken medication for PTSD for many years and this was not considered by the VA physician. The representative argues that the VA examination was inadequate and requests additional development. The United States Court of Veterans Appeals (Court) has provided detailed guidance for the development of claims for service connection for PTSD once the claimant has satisfied the initial burden of setting forth a well-grounded claim. Zarycki v. Brown, 6 Vet.App. 91 (1993). If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart Medal, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1993); Zarycki, 6 Vet.App. at 97. Where it is determined, through recognized military citations or other supportive evidence, that the veteran was engaged in combat with the enemy, and the claimed stressor is related to such combat, the veteran's lay testimony regarding the claimed stressor must be accepted as conclusive as to its actual occurrence and generally no further development for corroborative evidence will be required. Where the VA determines that the veteran did not engage in combat with the enemy, however, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Zarycki, 6 Vet.App. at 97. The Court also held that in addition to demonstrating the existence of a stressor, the facts must also establish that the alleged stressful event was sufficient to give rise to PTSD. Id. at 98-99. The RO has not requested from the veteran any details regarding stressful events that shed by medical evidence, between occurred during his active duty, or attempt to verify or corroborate whether he was awarded the Bronze Star Medal for heroism against the enemy or for meritorious achievement of service. The RO also did not attempt claimed to verify or corroborate the events generally alleged during the January 1993 VA examination through the United States Army and Joint Services Environmental Support Group (ESG) because the VA examiner did not diagnose PTSD. The representative argues that the VA should develop the claim for PTSD in accordance with the duty to assist under 38 U.S.C.A. § 5107(a) (West 1991). The veteran also seeks entitlement to service connection for residuals of malaria. During the January 1993 VA examination, the veteran stated that he contracted malaria while stationed in New Guinea. He stated that the last bout was approximately ten years ago. Examination and testing did not reveal residuals of malarial exposure and the physician's diagnosis was history of malaria, which was provided by the veteran, without evidence of recent activity or sequela. The threshold question is whether the veteran has presented evidence of a well-grounded claim. If a claimant has not presented a well-grounded claim, his appeal must fail. 38 U.S.C.A. § 5107(a); Grivois v. Brown, 6 Vet.App. 136, 140 (1994); Murphy v. Derwinski, 1 Vet.App. 78, 82 (1990). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. (Citation omitted.) In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet.App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet.App. 141, 143-44 (1992). Additionally, where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide such evidence on the issue. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). The record does not currently contain competent evidence showing that the veteran currently has any residual disability associated with the malarial exposure in 1943. VA has an obligation under 38 U.S.C.A. §§ 5103(a), 7722 (West 1991) to advise the appellant of the evidence necessary to complete an application for benefits. In this case, the veteran is hereby notified that preliminary review indicates that the "evidence necessary to complete the application" is evidence of continuity of symptomatology; medical evidence of the existence of residuals of malaria; and/or competent evidence of current residuals that are related to the in-service exposure. He remains under the obligation to provide such evidence. 38 U.S.C.A. § 5107(a). 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 a psychiatric disorder since separation from active duty. The evidence indicates he has received medical care from Fred C. LeMaster, D.O., 1151 South Peoria, Tulsa, Oklahoma, 74120, since 1958. After obtaining any needed authorization from the veteran, the RO should obtain copies of all these records. 2. An attempt should be made to verify the basis for the veteran's Bronze Star Medal through examination of the citation or award orders. The veteran should be requested to submit a copy of his Bronze Star Medal and/or a copy of the citation or award orders. If this is not available, the RO should ascertain whether this information is otherwise available from the service department or other official sources. 3. The veteran should be requested to provide more specific information, if possible, regarding the stressors he allegedly experienced during World War II, including the general stressful events related during the January 1993 VA examination. The veteran should be asked to provide the specific dates and locations for each event, the unit to which he was assigned at the time of each event, the names and units of persons he witnessed being wounded or killed, and the dates, places and circumstances of any deaths or injuries in as much detail as possible. The veteran should be advised that this information is necessary in order to obtain supportive evidence of the stressful events and that he must be as specific as possible because without such details an adequate search for verifying information cannot properly be conducted. 4. Unless the RO is able to determine that the Bronze Star Medal was issued for heroism against the enemy, and the claimed stressors are related to such events and the veteran's statements regarding the claimed stressor are accepted as conclusive as to their actual occurrence, provided the veteran's testimony is found to be credible and "consistent with the circumstances, conditions, or hardships of such service" (38 U.S.C.A. § 1154(b), the RO should review the veteran's list of stressors and the evidence in the claims folder and prepare a summary of all claimed stressors. This summary, together with a copy of the veteran's verified DD Form 214 and a copy of this remand, should be referred to the United States Army and Joint Services Environmental Support Group (ESG) 7798 Cisna Road, Springfield, Virginia 22050. ESG should be asked to verify the claimed stressors, or certify that the claimed stressors cannot be verified. Also, any available unit histories or similar documents which may be pertinent to the veteran's units should be requested. Any records or information obtained must be made part of the claims folder. 5. If a stressor may be presumed or is confirmed as a result of the foregoing development, the veteran should then be afforded a VA psychiatric examination. The RO must specify for the physician a description of such stressor(s) and instruct the examiner that only those events may be considered for the purpose of determining whether exposure to a stressor in service has resulted in current psychiatric symptoms. The examination should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations, and should include any appropriate psychological testing for PTSD. The examiner should utilize the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (3d ed. rev. 1987), in arriving at diagnoses, enumerating the specific diagnostic criteria satisfied and the specific findings meeting the criteria for any disorder found. If PTSD is diagnosed, the stressors supporting the diagnosis must be identified as must be the evidence documenting the stressors. The claims folder, including a copy of this remand decision, MUST be made available for review by the examiner prior to the examination. 6. The RO should review the record and ensure that all the above actions have been requested or completed as appropriate. The veteran and his representative then should be furnished with a supplemental statement of the case which summarizes the pertinent evidence, fully cites the applicable legal provisions not previously provided, and reflects detailed reasons and bases for the decision. The veteran 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 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 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).