BVA9504008 DOCKET NO. 93-05 769 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased disability rating for post- traumatic stress disorder, currently evaluated as 30 percent disabling. 2. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for bilateral hearing loss. 3. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for residuals of bilateral vertical osteotomies of the mandibular rami. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Theresa M. Catino, Associate Counsel INTRODUCTION The veteran served on active military duty from August 1968 to June 1971. In a March 1993 statement, the veteran's representative appeared to raise the issue of entitlement to a compensable disability rating for residuals of fragment wounds of the scalp with retained foreign bodies and the issue of entitlement to a finding of clear and unmistakable error. The representative has also raised the issue of entitlement to a permanent and total disability evaluation for pension purposes. These claims are not inextricably intertwined with the current appeal and are referred to the regional office (RO) for appropriate action. REMAND A complete and thorough review of the claims folder indicates that in 1993 the veteran was awarded Social Security Administration (SSA) disability benefits, effective from May 1992. According to a July 1993 letter from SSA to the veteran, several sets of medical records were used in SSA's determination that the veteran met the medical requirements for such disability benefits. Importantly, most of these records are not included in the claims file. The United States Court of Veterans Appeals (Court) has held that the decision of a Social Security administrative law judge is evidence which cannot be ignored and to the extent that its conclusions are not accepted, reasons and bases should be given therefor. Collier v. Derwinski, 1 Vet.App. 413, 417 (1991). Consequently, the Board of Veterans' Appeals (Board) concludes that an attempt should be made to obtain and to associate with the claims folder a copy of the decision awarding Social Security disability benefits and copies of the supporting medical records. In addition, at the August 1992 VA examination for post-traumatic stress disorder, the examiner diagnosed post-traumatic stress disorder and noted that the veteran reported that he had not worked since October 1981. Significantly, however, the psychiatric examiner did not discuss the extent of social and industrial impairment resulting from the veteran's post-traumatic stress disorder, nor did the examiner provide a finding of the veteran's functional impairment under the Global Assessment of Functioning Scale. An evaluation of the extent of social and industrial impairment is necessary when rating post-traumatic stress disorder. See, 38 C.F.R. Part 4, §§ 4.129, 4.130 (1994). In addition, the Board notes that the claims folder does not contain any recent records of outpatient treatment that the veteran received for his post-traumatic stress disorder. The Court has held that there is a continuing obligation on the VA to assist the veteran in developing the facts of his claim throughout the entire administrative adjudication. This obligation includes the duty to obtain records regarding the veteran's medical history. Murincsak v. Derwinski, 2 Vet.App. 363, 373 (1992). The veteran's representative has also raised the issue of entitlement to a total disability evaluation based on individual unemployability due to service-connected disability. The issue is inextricably intertwined with the issue of an increased evaluation for post-traumatic stress disorder that is currently before the Board. Therefore, it must be adjudicated by the RO before the Board can proceed with appellate review. Accordingly, the case is REMANDED to the RO for the following: 1. The veteran should be contacted and requested to furnish a complete list of all medical personnel and facilities from which he has received treatment for his service-connected post-traumatic stress disorder since 1992. The Board is particularly interested in records of any treatment that the veteran may have received from VA facilities. After obtaining the appropriate releases from the veteran where necessary, the health care providers should be contacted and requested to provide copies of all treatment records in their possession pertaining to the veteran. If these records are unavailable, that fact should be annotated in the claims folder. Any available records should be associated with the claims folder. 2. Copies of all medical records on which the decision was based and the decision by the Social Security Administration awarding disability benefits must be obtained and associated with the claims folder. If any of these records are duplicates of those already on file, that fact should be annotated in the claims folder. 3. Following the above, the veteran should be examined by a VA psychiatrist, who has not previously examined him, to determine the nature and extent of his service-connected post-traumatic stress disorder. The report of examination should include a detailed account of all manifestations of psychiatric pathology found to be present. If there are different psychiatric disorders, the psychiatrist should reconcile the diagnoses and should specify which symptoms are associated with and which disorders are part of or caused by the service-connected disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The psychiatrist should describe how the symptoms of the service-connected post-traumatic stress disorder affect the veteran's social and industrial capacity. The examiner should be requested to express an opinion as to the extent of industrial impairment which is the result of this disorder. All necessary special studies or tests, including psychological testing, are to be accomplished. The examiner should comment upon the veteran's functional impairment resulting only from his post-traumatic stress disorder by utilizing the Global Assessment of Functioning Scale found in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. It is imperative that the physician explain the significance of the numerical code assigned. The entire claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. 4. Thereafter, the RO should formally adjudicate the issue of entitlement to an increased rating for post-traumatic stress disorder and adjudicate the issue of a total disability evaluation on the basis of individual unemployability due to service- connected disability, with consideration of the provisions of 38 C.F.R. § 4.16(c), if applicable. Following completion of these actions, and, if the decision remains unfavorable, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, the case, in accordance with the current appellate procedures, should be returned to the Board for completion of appellate review. The issues of whether new and material evidence has been submitted to reopen the claims of entitlement to service connection for bilateral hearing loss and for residuals of bilateral vertical osteotomies of the mandibular rami are deferred pending the completion of the development of the veteran's increased rating claim. The purpose of this REMAND is to obtain clarifying evidence. No action is required of the veteran until further notice is issued. WILLIAM J. REDDY 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).