Citation Nr: 0000093 Decision Date: 01/04/00 Archive Date: 12/28/01 DOCKET NO. 98-10 382 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Mary C. Suffoletta, Associate Counsel INTRODUCTION The veteran had active service from July 1964 to July 1967. This matter comes to the Board of Veterans' Appeals (Board) from a July 1997 RO rating decision that denied service connection for PTSD. The veteran submitted a notice of disagreement in April 1998, and the RO issued a statement of the case in May 1998. The veteran submitted a substantive appeal in June 1998. In May 1999, the veteran withdrew his request for a hearing and submitted additional evidence directly to the Board. The veteran waived initial consideration of the evidence by the RO. FINDING OF FACT The veteran has submitted competent evidence tending to show the occurrence of stressors in service, current disability due to PTSD, and a link between the PTSD and the in-service stressors. CONCLUSION OF LAW The claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit held that, under 38 U.S.C. § 5107(a), VA has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the United States Court of Appeals for Veterans Claims issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Once a veteran has submitted evidence sufficient to justify a belief by a fair and impartial individual that a claim is well-grounded, the veteran's initial burden has been met, and VA is obligated under 38 U.S.C. § 5107(a) to assist the veteran in developing the facts pertinent to the claim. Accordingly, the threshold question that must be resolved in this appeal is whether the veteran has presented evidence that the claim is well grounded; that is, that the claim is plausible. In order for a claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Epps, 126 F.3d at 1468; Caluza, 7 Vet. App. at 506. Where the determinative issue involves medical causation or etiology, or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Epps, 126 F.3d at 1468. Further, in determining whether a claim is well- grounded, the supporting evidence is presumed to be true. King v. Brown, 5 Vet. App. 19, 21 (1993). Eligibility for service connection for PTSD requires the presence of 3 elements. There must be a clear medical diagnosis of PTSD (unequivocal and presumed to include adequacy of PTSD symptomatology and sufficiency of claimed in-service stressor), credible supporting evidence that the claimed inservice stressor actually occurred, and medical evidence of a causal nexus between current symptomatology and the specific claimed inservice stressor. Cohen v. Brown, 10 Vet. App. 128, 138, 139 (1997). In this case, documents received from the Social Security Administration (SSA) show that the veteran was awarded disability benefits by an Attorney Advisor in February 1998. The findings in the SSA Attorney Advisor decision note that the veteran has PTSD. Likewise, a diagnosis of PTSD "by history" was noted in a VA examination report in April 1997. For purposes of well-groundedness, this evidence tends to show current disability due to PTSD. Statements of the veteran are to the effect that he was stationed at Long Binh in Vietnam, and that he worked at an ammunition depot. The veteran's DD Form 214 indicates that his military occupational specialty (MOS) was that of an ammunition storage specialist. A review of the record shows that the claimed inservice stressors reported by the veteran include explosions and fire fights at the Long Binh Ammunition Supply Depot. The additional evidence submitted by the veteran in May 1999, consisting of an Inspector General report that lists dates of explosions at the Long Binh Ammunition Supply Depot during the period of the veteran's active duty, is sufficient corroborating evidence as to the inservice occurrence. Lastly, at the VA examination in April 1997, the veteran reported his experiences in Vietnam, and the examiner noted a diagnosis of PTSD by history from the veteran. The SSA decision by the Attorney Advisor included references to medical evaluations where the veteran again reported his Vietnam experiences, which implicitly supported a finding that the veteran has PTSD. For purposes of well- groundedness, the evidence of record is presumed true and tends to show a causal nexus. In light of this evidence, the Board finds that the veteran has presented a plausible claim for service connection for PTSD. As such, the claim is well grounded. ORDER The veteran's claim of entitlement to service connection for PTSD is well grounded. To this extent only, the appeal is granted. REMAND Having found that the veteran's claim is well grounded does not end the Board's inquiry; rather, in this case, it places upon VA the duty to assist the veteran in the development of his claim. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 82 (1990). The Board notes that the veteran underwent a VA examination in April 1997, and that the examiner noted a diagnosis of PTSD by history from the veteran. No opinion was included as to the etiology and/or current severity of the veteran's PTSD symptoms. Where the medical record is insufficient and the claim is well grounded, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See Suttman v. Brown, 5 Vet. App. 127, 128 (1993); Green (Victor) v. Derwinski, 1 Vet. App. 121, 124 (1991). Accordingly, another VA examination to access the nature and severity of the veteran's condition, and to obtain a nexus opinion as to the claimed inservice stressors must be obtained. Moreover, reports of medical evaluations of the veteran that were noted by SSA to support a finding of PTSD have not been obtained, and they should be. The United States Court of Appeals for Veterans Claims has held that when the VA is put on notice of the existence of relevant SSA records, the VA must seek to obtain those records before proceeding with the appeal. Lind v. Principi, 3 Vet. App. 493, 494 (1992). In view of the above, the case is REMANDED to the RO for the following actions: 1. The RO should ask the veteran to prepare a detailed list of all sources (VA and non-VA) of evaluation and treatment for PTSD since separation from service. Names and addresses of the medical providers, and dates of evaluations and treatment, should be listed. After obtaining any needed release forms from the veteran, the RO should directly contact the medical providers and obtain copies of the records not already in the file. 2. The RO should obtain copies from the Social Security Administration of the medical records used as a basis to award disability benefits to the veteran. 3. Then the RO should schedule the veteran for a VA PTSD examination. The examiner should state whether the veteran meets the diagnostic criteria of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, to support the diagnosis of PTSD; and if so, the examiner should specify which in- service stressor or stressors support the diagnosis. The examiner should support all opinions with a discussion of medical principles as applied to the medical evidence in this case. In order to assist the examiner in providing the requested information, the claims folder should be made available to the examiner for review in conjunction with the examination, and the examiner should acknowledge such review in the examination report. 4. After the above development, the RO should determine whether there is credible supporting evidence that the specific stressor or stressors supporting the diagnosis of PTSD actually occurred. This determination should reflect consideration of the provisions of 38 U.S.C.A. § 1154(b) (West 1991) (i.e., whether the veteran is a "combat" veteran) and 38 C.F.R. § 3.304(f) (1999). 5. The RO should then review the veteran's claim for service connection for PTSD. If action remains adverse to the veteran, an appropriate supplemental statement of the case should be sent to him and his representative, and they should be afforded an opportunity 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 further action unless notified otherwise, but may furnish additional evidence and argument while the case is in remand status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); Booth v. Brown, 8 Vet. App. 109 (1995); see also Kutscherousky v. West, 12 Vet. App. 369 (1999). The Board intimates no opinion as to the ultimate outcome of this case. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. J. E. DAY Member, Board of Veterans' Appeals