Citation Nr: 0006402 Decision Date: 03/09/00 Archive Date: 03/17/00 DOCKET NO. 98-10 208A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. C. Mackenzie, Associate Counsel INTRODUCTION The veteran served on active duty from September 1968 to April 1971, and his DD Form 214 indicates an additional one month and eleven days of prior active service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1997 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case has since been transferred to the Columbia, South Carolina VARO. The veteran requested a hearing before a VARO hearing officer in a statement received by the Columbia VARO in July 1998. However, in a December 1998 statement, he withdrew this hearing request. FINDING OF FACT The veteran served on active duty in the Republic of Vietnam during the Vietnam Era, and the record contains a current diagnosis of PTSD. CONCLUSION OF LAW The claim of entitlement to service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim of entitlement to service connection for PTSD is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). In other words, the Board finds that this claim is plausible and capable of substantiation. The Board has based this initial finding on private medical records received from the Lantana Clinic in Lantana, Florida, which reflect treatment for "post-traumatic stress syndrome," and on military records confirming service in the Republic of Vietnam during the Vietnam Era. However, for reasons detailed below, the Board will not render a decision on the merits of this claim at the present time. ORDER The claim of entitlement to service connection for PTSD is found to be well grounded. REMAND Generally, in order to establish service connection for a particular disorder, the evidence of record must demonstrate that a disease or injury resulting in a current disability was incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). However, VA regulations reflect that symptoms attributable to PTSD are often not manifested in service. Accordingly, service connection for PTSD requires a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in- service stressor), credible supporting evidence that the claimed in-service stressor(s) actually occurred, and medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f) (1999); Cohen v. Brown, 10 Vet. App. 128, 138 (1997) (citing Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996)). The evidence necessary to establish the occurrence of a stressor during service to support a claim for PTSD will vary depending on whether the veteran was "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60, 66 (1993). If the evidence establishes that the veteran was engaged in combat with the enemy or was a prisoner of war (POW), and the claimed stressor is related to combat or POW experiences (in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service), the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. Where, however, the VA determines that the veteran did not engage in combat with the enemy and was not a POW, or the claimed stressor is not related to combat or POW experiences, the veteran's lay statements, by themselves, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other credible evidence corroborating the stressor. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(d), (f) (1999); Gaines v. West, 11 Vet. App. 353, 357-58 (1998). Such corroborating evidence cannot consist solely of after-the- fact medical nexus evidence. See Moreau v. Brown, 9 Vet. App. 389, 396 (1996). In this case, the veteran's claimed stressors, as indicated in his lay statements and in the Brief on Appeal of his representative, include a jeep explosion, the deaths of several named individuals, a helicopter crash, an attack by North Vietnam sympathizers at a Saigon zoo, and several mortar round attacks at Phan Rang and Bien Hoa. To date, however, the RO has not requested that the United States Armed Services Center for Research of Unit Records (Unit Records Center) attempt to verify any of these alleged stressors. Therefore, in order to fully and fairly adjudicate the veteran's claim, this case is REMANDED to the RO for the following action: 1. The RO should contact the veteran and request that he provide specific details as to all stressful incidents in service that might be causally related to his current PTSD. The veteran should be requested to provide, if possible, specific names of persons involved, places of the events, dates of the events, and any other relevant information. He should also be requested to submit, if possible, affidavits from individuals with contemporaneous knowledge of the in-service events that he has described. 2. The RO should then review the claims file and make a list of all stressors alleged by the veteran. The RO should send this list and copies of any supporting documents, including the veteran's DD 214 and DA 20, to the Unit Records Center, which should be requested to make efforts to verify any specific in-service events described by the veteran. Results of the Unit Records Center's inquiries should be sent to the RO when available. 3. The RO should then complete a report of any in-service events described by the veteran which were verified by the Unit Records Center. If no such events were verified by the Unit Records Center, the RO should skip paragraph 4 and proceed to paragraph 5. If at least one event is verified by the Unit Records Center, such event(s) should be detailed in the report, and the RO should proceed to paragraph 4. 4. Then, the RO should afford the veteran a VA psychiatric examination to determine the nature, extent, and etiology of any current psychiatric disorders, including PTSD. The examiner should be furnished with the veteran's claims file and requested to review the entire claims file in conjunction with the examination. All tests and studies deemed necessary should be accomplished. In the examination report, the examiner should provide diagnoses for all psychiatric disorders noted upon examination. If PTSD is among the diagnoses noted, the examiner should provide an opinion as to whether it is at least as likely as not that the incurrence of this disorder is related to a verified in-service stressor. All opinions and conclusions expressed must be supported by a fully detailed rationale in a typewritten report. 5. Then, the RO should readjudicate the veteran's claim of entitlement to service connection for PTSD. If the determination of this claim remains adverse to the veteran, he and his representative should be furnished with a Supplemental Statement of the Case and given an opportunity to respond before the case is returned to the Board. The purpose of this REMAND is to obtain further development and adjudication, and the Board intimates no opinion, either factual or legal, as to the ultimate outcome warranted in this case. The veteran has the right to submit additional evidence and argument on this matter. See generally Kutscherousky v. West, 12 Vet. App. 369 (1999). However, no action is required on the part of the veteran until he is so notified by the RO. ________________________________ WARREN W. RICE, JR. Member, Board of Veterans' Appeals