BVA9502512 DOCKET NO. 93-08 114 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a psychiatric disorder. 2. Entitlement to an increased evaluation for pes planus, currently evaluated as 10 percent disabling. 3. Entitlement to a permanent and total disability rating for pension purposes. ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from August 1952 to August 1955. This appeal arose from a May 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The RO denied entitlement to service connection for a psychiatric disorder, an increased evaluation for pes planus, and a permanent and total disability rating for pension purposes. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. REMAND A review of the service medical records discloses that the veteran was treated for psychiatric symptomatology diagnosed as "acute psychosis." He was examined by VA in October 1955, two months after his discharge from service. The VA examiner noted that psychological testing revealed a possible paranoid schizophrenic process in a passive dependent with an intellectualization defense. The examination diagnosis was schizoid personality. On file is a brief note dated in July 1991 from Leonard M. Rothstein, M.D. He reported that the veteran had been under his psychiatric care from February 1981 to March 1984, for treatment of depressive reaction and paranoid personality disorder. Dr. Rothstein's treatment reports are not on file. The claims file contains a letter dated in June 1991 from the medical records clerk of the Springfield Hospital Center of Sykesville, Maryland. The clerk advised that the veteran had been hospitalized at the facility from January 1969 to November 1970, for schizophrenic reaction, paranoid type. It was noted that the records pertaining to this hospitalization had been microfilmed and sent to the archives in Philadelphia. The records pertaining to this admission are not on file. The veteran has been unable to report for VA examinations because of his confinement at the United States Medical Center for Federal Prisoners. In a May 1993 letter, a psychiatric social worker from the Federal medical facility advised that the veteran would soon be released and placed in a facility in the community. The Board is of the opinion that more complete evidence as to the veteran's post service treatment for his psychiatric illness and comprehensive VA examinations would materially assist in the adjudication of his appeal. Furthermore, there is a possibility that he may be in receipt of Social Security Disability Benefits, and the medical records utilized in the award of such benefits would be extremely helpful in view of the claim for non service- connected disability pension benefits. 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) (West 1991); 38 C.F.R. § 3.103(a) (1994), the Board is deferring a final determination of the issues prepared and certified for appellate review pending a REMAND of the case to the RO for further development as follows: 1. The RO should contact the veteran and request that he identify all sources of psychiatric treatment since service. After obtaining any necessary authorization, the RO should request and associate with the claims file photocopies of the complete records pertaining to the veteran's post service psychiatric treatment from all sources identified including those pertaining to the hospitalization from January 1969 to November 1970 at the Springfield Hospital Center, such records having been microfilmed and archived in Philadelphia, Pennsylvania; and those pertaining to his treatment from 1981 to 1984 by Leonard M. Rothstein, M.D., 1190 West Northern Parkway, Baltimore, Maryland 21210. 2. If it has been determined that the veteran is receiving Social Security Disability Benefits, the RO should obtain from the Social Security Administration the records pertinent to his claim as well as the records relied upon concerning that claim. If records pertaining to such claim and medical evidence utilized in processing such claim are not available, that fact should be entered in the claims file. 3. The veteran should be scheduled for a comprehensive medical examination to determine the nature and extent of severity of any disabilities which may be present, including his diagnosed pes planus, residuals of prostate cancer, diabetes mellitus, and hypertension. All indicated studies should be undertaken. The examiner(s) must be required to provide an opinion(s) as to the impact of the veteran's disabilities on his ability to obtain and retain substantially gainful employment. Any opinion expressed must be accompanied by a complete rationale. The claims file must be made available to and reviewed by the examiner(s) prior to the examination(s). 4. The RO should schedule the veteran for an examination by a VA psychiatrist to determine the nature and extent of severity of any psychiatric disorder(s) which may be present. The examination is to be conducted in accordance with the diagnostic procedures outlined in Chapter 14 of the VA Physician's Guide for Disability Evaluation Examinations. All indicated studies including psychological studies should be undertaken. The psychiatric examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (3rd ed. rev., 1987), and explain what the assigned score represents. The claims file must be made available to and reviewed by the examiner prior to the examination. The examiner must be requested to provide an opinion as to onset of any psychiatric disorder(s) found on examination, and as to whether it is at least as likely as not that any such disorder(s) found on examination are related to the service reported acute psychosis. An opinion must also be expressed as to the impact of the psychiatric disorder(s) found on examination on the veteran's ability to engage in substantially gainful employment. 5 Thereafter, the RO should review the examination reports including the requested opinions to ensure that they are in complete compliance with the instructions contained in this REMAND. If the examination reports are not in complete compliance, appropriate corrective action is to be implemented at once. 6. Then, the RO should evaluate the veteran's disabilities and assign a percentage evaluation for each. 7. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issues of entitlement to service connection for a psychiatric disorder, increased evaluation for pes planus, and a permanent and total disability rating for pension purposes consistent with the criteria under 38 U.S.C.A. §§ 1502(a)(1), 1521(a) (West 1991); 38 C.F.R. §§ 3.321(b)(2), 4.15, 4.16, 4.17, 4.25 (1994); as well as the provisions of Talley v. Derwinski, 2 Vet.App. 282 (1992); Brown v. Derwinski, 2 Vet.App. 444 (1992); and Roberts v. Derwinski, 2 Vet.App. 387, 390 (1992). If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. The supplemental statement of the case must include the criteria for all of the appropriate diagnostic codes under which the RO has rated each of the appellant's disabilities. The RO must include a discussion of the average person standard and unemployability standards by which a permanent and total disability rating for pension may be assigned. The veteran and his representative should then be provided a reasonable opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, 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. ALBERT D. TUTERA 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) (1993).