BVA9500555 DOCKET NO. 93-09 027 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Anderson, Counsel INTRODUCTION The appellant had active duty from December 1965 to January 1968. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of March 1992, from the Montgomery, Alabama, regional office (RO). The decision denied service connection for post-traumatic stress disorder (PTSD). The notice of the rating action also informed the appellant that service connection had been denied for rheumatic fever, rheumatic heart disease, duodenal ulcer, and a skin condition. In his notice of disagreement, the appellant disagreed with the rating action, except as to a duodenal ulcer, and added a claim for benefits under the provisions of 38 U.S.C. § 1151 based on hospitalization by the Department of Veterans Affairs (VA) in June 1991. The Board notes that the appellant's original claim to establish service connection for rheumatic fever and heart disease had been denied by rating action of April 1968. It appears that the appellant is attempting to reopen these claims and to amend his claim to add service connection for a skin disability and entitlement to benefits under the provisions of 38 U.S.C. § 1151. These matters are not developed or certified for appellate review. They are referred to the RO for appropriate consideration. REMAND Except for the reasonable doubt standard, all regulations cited in the statement of the case refer to principles concerning increased evaluations of service-connected disorders, rather than to the applicable laws and regulations pertaining to service connection. At a VA examination in August 1983 the veteran reported that he had sought treatment from Dr. Morris Jones in Cleveland, Ohio, in 1973 for mental depression. In a statement dated in August 1991, the veteran indicated that information from a private doctor he had seen in Cleveland in 1973 was not available. He stated that he was treated at the VA Medical Center, Tuskegee, Alabama, from April 1991 to the present. No attempt has been made to obtain records of this treatment. In statements in support of claim received in August 1991 and February 1992, the appellant furnished information relating to purported stressful events in service. These purported events have not been made the subject of verification by the service department. Moreover, it does not appear that the claims file was made available to any examiner conducting a psychiatric evaluation of the appellant. To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should request the veteran to identify all sources of psychiatric treatment received by him, and to furnish signed authorizations for release to the VA of private medical records in connection with each non-VA source he identifies. Copies of the medical records from all sources he identifies (not already in the claims folder) should then be requested, including records from Dr. Morris Jones and records from the VA Medical Center, Tuskegee, Alabama. All records obtained should be added to the claims folder. 2. The RO should determine whether the information previously supplied by the appellant contains sufficient detail to allow meaningful research to obtain supportive evidence of the stressful events. If not, the RO should instruct the appellant to give more detailed information concerning recognizable stressors in service, for later verification by the United States Army and Joint Services Environmental Support Group (ESG). His response, if any, should be associated with the claims file for RO, ESG, and appellate review. 3. Thereafter, the RO should prepare a summary of all the claimed stressors. This summary, and all associated documents including the appellant's military personnel records, should be sent to ESG, 7798 Cissna Road, Springfield, Virginia 22150. ESG should be requested to provide any information which might corroborate the veteran's alleged stressors. All information obtained should be associated with the claims file. 4. Following the above, the RO must make specific determinations, based upon the complete record, as to whether the appellant "engaged in combat with the enemy" and whether the appellant was exposed to a stressor or stressors in service, and if so, the nature of the specific stressor or stressors. If the RO determines that the record establishes the existence of a stressor or stressors, the RO must specify what stressor or stressors in service it has determined are established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. If the record establishes the existence of a stressor, the RO must determine whether or not service connection for PTSD may be granted based on the current medical evidence. 5. If, and only if, the RO determines that the record establishes the existence of a stressor or stressors but that the current medical evidence is inadequate, then the RO should arrange for the veteran to be accorded another psychiatric examination by a psychiatrist who has not previously examined him to determine the diagnoses of all psychiatric disorders that are present. The RO must specify for the examiners the stressor or stressors that it has determined are established by the record and the examiner must be instructed that only those events may be considered for the purpose of determining whether exposure to a stressor in service has resulted in current psychiatric symptoms and whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. The examination report should reflect review of pertinent material in the claims folder. The examiner should integrate the previous psychiatric findings and diagnoses with current findings to obtain a true picture of the nature of the veteran's psychiatric status. If the diagnosis of PTSD is deemed appropriate, the examiner should comment upon the link between the current symptomatology and one or more of the inservice stressors found to be established by the RO. The report of examination should include the complete rationale for all opinions expressed. All necessary special studies or tests, to include psychological testing and evaluation, such as the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorders, should be accomplished. The claims folder must be made available to the examiner prior to the examination. 6. The RO should then review the record and ensure that all the above actions have been completed. When the RO is satisfied that the record is complete and the psychiatric examination is adequate for rating purposes, the claim should be readjudicated. If the benefit sought on appeal is not granted to the veteran's satisfaction, a supplemental statement of the case should be prepared and the veteran and his representative should be given a reasonable period of time for reply. Thereafter, the claim should be returned to the Board for further review, if otherwise in order. No action is required of the veteran until he receives further notice. The Board does not indicate any factual or legal conclusions as to any final outcome warranted in the appeal. GARY L. GICK 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 deter- mination. 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).