BVA9507406 DOCKET NO. 93-14 276 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart ATTORNEY FOR THE BOARD Keith W. Allen, Associate Counsel INTRODUCTION The veteran served on active duty from May 1968 to December 1969. Most of his service was in the Republic of Vietnam during the war. In March 1982, the Board of Veterans' Appeals (Board) denied the veteran's claim for service connection for an acquired psychiatric disorder (claimed by him to be due to experiences that he had while stationed in the Republic of Vietnam during the war). A decision of the Board is final, with the exception that a veteran may later reopen his claim if he submits evidence which is both new and material. See 38 U.S.C.A. §§ 5108, 7104 (West 1991). The veteran has made several attempts to reopen his claim since the 1982 decision of the Board; all, however, were denied by the RO. On file, though, are records that he submitted during the course of this appeal concerning treatment that he received at a VA medical center for PTSD in 1991 and 1992 (he also submitted a statement from a private psychiatrist showing treatment for PTSD in 1990 and 1991). The Board finds this evidence is new and material in the sense that it shows a clinical diagnosis of the condition and relates it to service. See 38 C.F.R. § 3.156; Colvin v. Derwinski, 1 Vet.App. 171 (1991); Manio v. Derwinski, 1 Vet.App. 140 (1991). Therefore, the claim is reopened and will be reviewed on a de novo basis (i.e., based on the entire record). REMAND The veteran's claim is well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is not inherently implausible. However, for reasons discussed below, the Board finds that the case should be remanded since further action is required by VA in order to comply with its duty to assist the veteran in developing evidence which is pertinent to his claim. See 38 C.F.R. §§ 3.103, 3.159. The veteran's claim for service connection for PTSD was denied in previous decisions on the basis that there was no clear diagnosis of the condition. See 38 C.F.R. § 3.304(f). Records show that he was examined by VA psychiatrists (in connection with claims for compensation benefits) in January 1981, October 1988, September 1991, and March 1992, but PTSD was not diagnosed. Instead, he was found to have a chronic and severe antisocial personality disorder and a chronic and severe history of drug abuse. He has also suffered emotionally as a result of having to deal with physical disability caused by a stroke (cerebral vascular accident-(CVA)) that he had in April 1991. Since his stroke, he has undergone extensive physical therapy to help him regain muscle coordination in various parts of his body and to help him speak. There is, however, evidence on file which lends support to the veteran's claim. For example, while receiving treatment in 1991 and 1992 at a VA medical center (from Alan H. Peck, M.D., and William A. Canter, Ph.D.), PTSD was diagnosed and causally related to stressors that the veteran said he experienced while stationed in Vietnam during the war (the diagnosis made by Dr. Peck was noted by the VA psychiatrist who did not diagnose the condition after examining the veteran in September 1991). PTSD was also diagnosed by Richard Schlottman, M.D. (of South Baltimore Family Health Centers, Inc.), while the veteran was undergoing treatment in 1990 and 1991. See January 1992 statement from Dr. Schlottman. The veteran should be scheduled for another VA psychiatric examination to reconcile the conflict in the various diagnoses that have been made. This obligation is ancillary to VA's duty to assist him in developing evidence pertinent to his claim. Littke v. Derwinski, 1 Vet.App. 90 (1990). The veteran's service personnel records (including DA Form 20) show that he was stationed in Vietnam from October 1968 to December 1969 and that his occupational specialty was that of a military policeman (MP). He was awarded the standard battery of medals for his service in Vietnam; however, none reflect combat service per se, so he is not entitled to a conclusive presumption as to the validity of stressors that he has alleged to be due to combat. See 38 C.F.R. § 3.303(f) and a December 1991 letter from him listing his alleged stressors. Nevertheless, this does not preclude awarding service connection, if the stressors that he has alleged can be verified by other means, with sufficient certainty, and causally linked to a current diagnosis of PTSD, assuming of course that it is ultimately determined that he in fact has this condition. Since his claim for service connection for PTSD was denied on other grounds in previous decisions (i.e., based on a lack of a current diagnosis), a discussion of the validity of the stressors claimed by him was not necessary. However, in light of the need for another psychiatric examination (during which time the condition may possibly be diagnosed), validation of the stressors he claims becomes essential. Because of this, more specific information concerning the events that allegedly took place in Vietnam would be helpful. For the aforementioned reasons, the case is REMANDED for the following action: 1. The RO should contact the veteran and request that he provide as much detailed information as possible regarding the incidents that he alleges took place while stationed in Vietnam. (A large portion of this information was provided in his December 1991 letter in which he identified names of fellow servicemen, friends of his, which he says were killed while stationed in Vietnam.) He should be sure to include dates, unit assignments, and geographical locations when providing this information. 2. The RO should obtain: -Daily Journals, Operational Reports-Lessons Learned (OR-LLs), Combat Operations After Action reports (COAARs), Unit Histories. National Archives and Records Administration Washington National Records Center Military Archives Division Washington, D.C. 20409 -Morning Reports National Archives and Records Administration ATTN: NCPMA-O 9700 Page Boulevard St. Louis, MO 63132-5200 3. Thereafter, the RO should forward the veteran's pertinent service records and his account of service stressors to the United States Army and Joint Services Environmental Support Group (ESG) at 7798 Cissna Road, Springfield, Virginia 22150. The ESG should be asked to verify the claimed stressors. 4. When the above action has been completed, the veteran should undergo a psychiatric examination by a board of two psychiatrists, who have not previously examined him, to determine the nature and etiology of any psychiatric disorder present, and particularly to diagnose or rule out PTSD. The claims folder must be made available to, and reviewed by, the examiners prior to their examination of the veteran. They should specifically note any service stressors which have been verified. 5. Thereafter, the RO should review the claim for service connection for PTSD, and consideration should be given to all controlling legal and regulatory authority, including 38 C.F.R. § 3.304(f). Should the claim for service connection for PTSD be denied, the veteran and his representative should be furnished a supplemental statement of the case and given a reasonable opportunity to respond. Then the case should be returned to the Board for further appellate review. M. CHEEK 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).