BVA9508075 DOCKET NO. 90-21 264 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a rating in excess of 30 percent for post- traumatic stress disorder, to include a total rating for compensation purposes based on individual unemployability. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Associate Counsel INTRODUCTION The veteran served on active duty from April 1967 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) of St. Petersburg, Florida. Originally, in addition to the increased rating issue on the title page, the appeal included issues of entitlement to service connection for alcohol abuse secondary to post-traumatic stress disorder, and entitlement to a temporary total rating for a period of hospitalization, pursuant to 38 C.F.R. § 4.29. This case has been remanded by the Board in October 1990 and July 1991. While the case was in remand status, service connection for alcoholism was granted as was the temporary total rating for the period in question. In addition, an increased rating of 30 percent was assigned for the post-traumatic stress disorder (PTSD). The veteran has appealed that issue seeking a higher rating, to include a total rating for compensation based on individual unemployability. The case was returned to the Board in July 1994. It was referred to the veteran's representative at that time. Following the entry of a March 1995 Informal Brief into the record, the case was forwarded to this section of the Board for further appellate review. REMAND The veteran's representative has contended, in the aforementioned March 1995, Informal Brief, that the case must be remanded yet again. In view of the contentions advanced, and guidance provided by the United States Court of Veterans Appeals (Court), the Board reluctantly agrees. Part of the reason for this additional remand, as cited below, stems from cases of the Court decided after this case had been returned to the Board following the development requested in the last remand. The VA has a duty to assist a veteran in developing facts pertinent to a potentially well grounded claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103, 3.159 (1994). That duty includes obtaining medical records and medical examinations where indicated by the facts and circumstances of an individual case. See Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App. 90 (1990). The record reflects that the veteran is receiving Social Security Administration (SSA) benefits. He was asked to provide a copy of his award letter and the medical evidence that was used by SSA in making its determination. He forwarded a letter with information concerning his monthly benefit, and reported that SSA had used his VA medial records in making its determination. The record does not contain, however, the basis of the determination of the SSA, i.e., whether he was found disabled solely because of this PTSD, or whether there were other disorders which rendered him disabled under the SSA criteria. The representative argues that such information is needed and that the RO should attempt to get it. The Court has indicated that where there has been a determination that the veteran is entitled to SSA benefits, the records concerning that decision are often needed by the VA for evaluation of pending claims, and must be obtained. See Murincsak v. Derwinski, 2 Vet.App. 363 (1992). See also 38 U.S.C.A. § 5106 (West 1991). In addition, at the time of the January 1993 VA psychiatric examination, the veteran reported continuing treatment at the James A. Haley VA Hospital, and with a private physician. We conclude that those records should be obtained prior to our entering a decision in this case. Furthermore, in view of the guidance of the Court in recent cases, we conclude that the 1992 examination is no longer adequate to assign an evaluation. See Massey v. Brown, 7 Vet.App. 204 (1994); Gary v. Brown, No. 92-1483 (U.S. Vet. App. Dec. 14, 1994). Essentially, these cases direct examiners to address the extent of functional and industrial impairment from the veteran's service-connected disabilities. Additional testing and evaluation are required, as set forth below. In this regard, it is noted that the veteran reported on several claims forms that he last worked in 1988. At the time of the VA examination in January 1993, it was reported that he last worked in 1991. Clarification of this point is also needed. In view of the foregoing, this case is REMANDED for the following actions: 1. The RO should, with the veteran's assistance as indicated, attempt to obtain medical records of any psychiatric treatment that the veteran has had since at least January 1990. This information should include copies of the clinical records from the private psychiatrist/physician that he sees, as well as records from any VA outpatient treatment he has received. As indicated, the veteran should provide names, addresses, and approximate dates of treatment, as well as any needed release forms. In the event records requested are not obtained, the claims folder should contain documentation of the attempts made to obtain the records. The appellant and his representative should also be notified of the negative results. 38 C.F.R. § 3.159. 2. The RO should, with the veteran's assistance as needed, attempt to obtain a copy of the SSA award letter to determine the basis for the SSA determination that he is disabled. The award letter should determine the basis for the award, i.e., whether solely on the basis of PTSD, or whether other disorders were also considered. 3. The veteran should again be asked to certify when he was last gainfully employed, and whether he currently performs any duty, including managing or cutting hair at the barbershop that he reportedly owns. 4. The RO should schedule the veteran for a comprehensive VA psychiatric examination. This study must be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. The claims file must be made available to and reviewed by the examiner prior to the requested study. The examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3d ed. rev., 1987), and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. When the aforementioned development has been accomplished the case should be reviewed by the RO. In the event the benefits sought are not granted, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable opportunity to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration. No action is required of the veteran until he is notified. MICHAEL D. LYON 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).