BVA9503966 DOCKET NO. 93-12 462 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for headaches. Entitlement to an increased rating for post-traumatic stress disorder, currently rated 70 percent disabling. Entitlement to a total rating based on individual unemployability due to service connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Appellant, his wife, his brothers, and his sister ATTORNEY FOR THE BOARD James J. Dunphy, Counsel INTRODUCTION The veteran had active service during the Vietnam Era. This appeal to the Board of Veterans' Appeals (Board) arises from an October 1989 decision by the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO) denying a rating in excess of 50 percent for post-traumatic stress disorder (PTSD). The rating was increased in a March 1991 rating decision to 70 percent. In a May 1992 rating action, a total rating based on individual unemployability due to service- connected disability was denied, and, in February 1993, the RO determined that the veteran had not submitted new and material evidence to reopen a claim for entitlement to service connection for headaches. REMAND A notation on the veteran's claims folder indicates that this claims folder is "Volume III of III." The other two volumes are not available for review. The veteran indicated in an October 1992 communication that he wished to reopen his claim for entitlement to service connection for headaches. He did not submit any form of evidence with this claim. A review of the medical evidence in the sole claims folder before us reveals a February 1991 letter from his VA treating physician, who indicates that the veteran has headaches. No basis is given as to the etiology of the headaches, and there is no medical opinion or other evidence indicating whether the headaches are related to incidents of service or to the service- connected PTSD. Based on the evidence currently before the Board, the veteran runs the risk of having his claim found not to be plausible and hence not well grounded. If this is the case, the veteran's claim must be dismissed. Therefore, the veteran should submit any additional evidence he can with regard to the issue of whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for headaches. In a letter to the veteran's Senator in March 1992, the RO Director indicated that the veteran was to be scheduled for a review examination in December 1992. A record of this examination, if it took place, is not available for review, and no reference is made to this examination in any of the rating decisions or statements of the case. The veteran last underwent a complete psychiatric examination in December 1990. Since that time, he has required psychiatric outpatient treatment and hospitalization. Accordingly, a new and comprehensive examination would be most helpful in reviewing the veteran's claim. The Board further notes reports from VA medical professionals, indicating that the veteran has required regular treatment for his PTSD. Available for review are some treatment records from December 1993. However, these are the only records available subsequent to February 1990. The records of VA medical treatment would greatly assist the Board in determining the proper evaluation for the veteran's PTSD. In his hearing testimony, the veteran indicated that he had begun a period of Vocational Rehabilitation, but was dropped from the program. The ability of a veteran to undergo Vocational Rehabilitation is relevant to a consideration of whether he is totally precluded from all forms of gainful employment. Accordingly, it would be appropriate to secure the Vocational Rehabilitation and Training Folder. Finally, the veteran's wife indicated that the veteran is in receipt of benefits administered by the Social Security Administration as a result of a disability. She further indicated that these benefits were awarded in 1986. While it is a normal requirement to secure these records, we conclude that it is not necessary in this case. These records would document the veteran's condition at the time that the Social Security benefits were awarded. As the issues before us turn on the veteran's current symptomatology, the Board concludes that remanding the case to secure the Social Security Administration records would serve no useful appellate purpose. Accordingly, the case is remanded to the RO for the following actions: 1. All records of treatment afforded the veteran by the VA should be secured and associated with the claims folder. 2. The RO should secure the veteran's Vocational Rehabilitation and Training Folder and associate these records to the claims folder. 3. The RO should secure the other two volumes of the veteran's claims folder. If these volumes are unavailable, the RO should document all actions taken to secure the missing volumes, and then certify the volumes as lost. 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 files 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 (3rd ed. rev., 1987) and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. 5. Following completion of the foregoing, the RO must review the claims folders and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not include all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. When the requested development is completed, the RO should review the case. In determining if a total rating is warranted, the RO should, if otherwise appropriate, consider 38 C.F.R. § 4.16 (c) (1994). If the benefits sought are not granted, the veteran and his representative should be provided with an appropriate supplemental statement of the case. They should also be given a reasonable period to respond. The case should then be returned to the Board for further appellate consideration. The purposes of this remand are to obtain additional information and to assist the veteran in the development of his claim. No inference should be drawn regarding the merits of the claim, and no action is required of the veteran until he is notified. J. U. JOHNSON 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. (CONTINUED ON NEXT PAGE) 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).