BVA9507904 DOCKET NO. 93-12 382 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to an increased (compensable) evaluation for bilateral hearing loss. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from March 1966 to March 1969. This appeal arose from an October 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The RO denied entitlement to service connection for post-traumatic stress disorder and an increased (evaluation) for bilateral hearing loss. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. REMAND Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the disorder, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). In this regard, the veteran served as an infantry weapons repairmen with the United States Marine Corps, and served a tour of duty in Vietnam from May 1968 to February 1969. His decorations include the Vietnam Service Medal, and administrative records on file note his participation in three combat operations against the enemy in Vietnam. The veteran is not shown have been awarded the Combat Action Ribbon or other decoration reflective of combat activity. The Board observes, however, that the Combat Action Ribbon was only authorized by the Secretary of the Navy eight days prior to the veteran’s departure from Vietnam. Hence, in determining whether the veteran has a verifiable stressor a retrospective review of his eligibility for this award is warranted. The Board further observes that Headquarters, United States Marine Corps advised VA in a December 1992 letter that it was unable to verify the veteran's claimed stressor as it did not know the name of the unit to which a service comrade with the last name "Williams" was attached. The Board observes, however, that the information supplied to Headquarters, United States Marine Corps in an effort to verify the claimed stressor is not as complete as that which is located elsewhere in the claims file. For example, during the veteran’s March 1992 VA compensation examination reference was made to the death of a "best friend" in Vietnam on July 5, 1968, and the claim that he was required to identify the remains of this Marine. If this Marine is the "L/CPL "Willie" Williams" identified in a September 1991 statement by the veteran, the reference to July 5, 1968, warrants further development in light of the fact that the Directory of Names on the Vietnam Veterans War Memorial discloses that United States Marine Lance Corporal Robert Eugene Williams died on July 5, 1968. Accordingly, further action is required, including the development of a detailed stressor statement for submission to Headquarters, United States Marine Corps. The veteran has been diagnosed with post-traumatic stress disorder on several occasions by VA psychiatrists on examination, and during the course of inpatient and outpatient care. These diagnoses all appear to have been based on a history which has yet to be verified. As an examination based on a questionable history is inadequate for rating purposes, West v. Brown, 7 Vet.App. 70, 78 (1994), it is necessary that the veteran be provided an examination where the examiner has the accurate history of the veteran's military service. Therefore, further development is warranted. Therefore, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), this case is REMANDED for the following development: 1. The RO should request from the veteran a statement containing as much detail as possible regarding the alleged stressful events to which he was exposed in service. The veteran should be requested to provide specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of the events, his service units in Vietnam, duty assignments and the names, ranks, unit of assignment and any other identifying information concerning any other individuals involved in the events. In particular the veteran should identify the unit in which L/CPL "Willie" Williams" was a member. He should be told that the information is necessary to obtain supportive evidence of the stressful events and that failure to respond may result in adverse action. 2. The information provided by the claimant concerning the specific circumstances of the claimed stressors and a copy of the veteran's service records and his DD 214 record of service should be sent to the Commandant of the Marine Corps, Headquarters, United States Marine Corps (Code MMSB-15), Quantico, Virginia 22134- 0530 for verification of the stressors claimed by the veteran. Headquarters, United States Marine Corps (Code MMSB-15) is further requested to identify the unit to which Lance Corporal Robert Eugene Williams was assigned at the time of his death on July 5, 1968, and the relative location of Corporal Williams’ unit on that date vis-a-vis the location of H & S Company, First Battalion, Seventh Marines, First Marine Division, on July 5, 1968. Finally, Headquarters, United States Marine Corps is requested to review the veteran’s eligibility to wear the Combat Action Ribbon based on the "Combat History" noted in his Service Record Book. 3. Following receipt of reports from the above offices, and the completion of any additional development warranted or suggested by that office, the RO should prepare a report detailing the nature of any combat action, or inservice stressful event, verified by the United States Marine Corps. If no combat or stressor has been verified, the RO should so state in its report. This report is then to be added to the claims file. 4. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a board of psychiatrists, if available, who have not previously seen or treated him. This examination is to be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of any psychiatric disorder which may be present. All indicated studies, including post-traumatic stress disorder sub scales, are to be performed. In determining whether or not the veteran has post-traumatic stress disorder due to an inservice stressor the examiners are hereby notified that only the verified history detailed in the reports provided by the United States Marine Corps and/or the RO may be relied upon. If the examiners believe that post-traumatic stress disorder is the appropriate diagnosis they must specifically identify which stressor(s) detailed in the United States Marine Corps and/or the RO's report is responsible for that conclusion. Any and all opinions expressed must be accompanied by a complete rationale. The examiners should assign a Global Assessment of Functioning Score which is consistent with the provisions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (3rd. ed., 1987) (DSM-III-R), and define what the assigned score means. The entire claims folder and a copy of this REMAND must be made available to and reviewed by the examiners prior to the examination. 5. Following the completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination reports to verify that any diagnosis of post-traumatic stress disorder was based on the verified history provided by the United States Marine Corps and/or the RO. If the examiners relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the United States Court of Veterans Appeals has held that a diagnosis of post-traumatic stress disorder, related to service, which is based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 6. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for post-traumatic stress disorder. The claim of entitlement to a compensable evaluation for bilateral hearing loss is deferred. If the benefit requested on appeal is not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. DEREK R. BROWN 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).