BVA9504970 DOCKET NO. 93-13 666 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUE Entitlement to service connection for a psychiatric disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Richard E. Coppola, Associate Counsel REMAND The veteran had active service from December 1945 to November 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of January 1992 from the San Juan, Puerto Rico, Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a psychiatric disorder. The veteran's service medical records show that he was referred to the United States Naval Base Hospital #21 on August 10, 1946, following prolonged difficulties with fellow shipmates and a physical altercation with the coxswain several days prior to admission. The initial diagnosis was personality disorder, later changed to psychoneurosis, anxiety. It was noted that the condition did not exist prior to service. He was then transferred in September 1946 for further evaluation and assessment by a medical board. Based on the examination and evaluation at that time, the diagnosis was redefined as "no disease (temperamentally unsuited)." The Board of Medical Survey concurred with that diagnosis and the veteran was considered unfit for further military service. It was also determined that the veteran's condition existed prior to active duty and was not aggravated during service. The Board determined that his civilian capacities were unimpaired since he had no disabling mental or physical condition at that time. The October 1946 report of medical examination at separation notes a history of psychoneurosis anxiety in 1946, but reports that the veteran did not have an abnormal psyche at that time. At the personal hearing the veteran testified that he worked for the Maritime Army Transports, i.e., Merchant Marines, for two years subsequent to discharge from active service, but was fired for continued altercations with fellow employees. Transcript, p, 6 (June 1992). It remains unclear whether there are records supporting his testimony. The veteran further testified that he initially received psychiatric care in 1985 at the New York, New York, VA Hospital. Tr., at 7, 12-13. The RO requested treatment records from that facility; but the response states that there are no records of treatment for the veteran at that facility. He also testified that he received treatment beginning in approximately 1989 at the Mayaguez VA Outpatient Clinic, Puerto Rico. Tr., at 8. The RO requested and received treatment records from that facility which are dated from January 1991 to April 1992. The RO determined that these records did not disclose treatment for a psychiatric disorder. These records show that he was seen at the outpatient clinic on March 3, 1992, for mental health services. These records are not clearly legible and it appears that the diagnosis was changed or superimposed with another diagnosis. The statement of the case does not refer to these records. The Board finds that the reported diagnosis should be clarified. Given the evidence in the service medical records in conjunction with the veteran's acknowledgment of continued feelings of nervousness since active duty, See, Tr., p. 2, the Board finds that he should be afforded a VA examination to determine whether there is any current psychiatric disability related to service. Under the present circumstances, the Board finds that additional development of the evidence is necessary. Accordingly, the case is REMANDED for the following actions: 1. The veteran should identify the names and addresses of any medical care providers, VA or otherwise, who have treated him for psychiatric complaints since April 1992. The RO should also obtain a legible copy of the March 3, 1992, VA treatment records from the Mayaguez VA Outpatient Clinic, Puerto Rico. After obtaining any needed authorization from the veteran, the RO should obtain copies of all these records. 2. An attempt should be made to obtain any medical records, such as United States Public Health Service records, that are related to the veteran's employment with the Maritime Army Transports, i.e., Merchant Marines, apparently between 1947 and 1951. The RO may request the veteran to provide additional details pertaining to that employment. 3. The veteran should then be afforded a VA psychiatric examination in order to determine the veteran's current psychological assessment. The examination should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations, and should include all appropriate tests and evaluations, including any necessary psychological testing. The psychiatrist should review the evidence in the claims folder, and provide a diagnostic formulation in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (3d ed. rev. 1987). The psychiatrist should be requested to express an opinion as to the etiology of any current psychiatric disorders and the degree of probability, if any, that any psychiatric disorder currently present is related to service. It is essential that the claims folder, including a copy of this remand decision, be made available for review by the psychiatrist prior to the examination. 4. The RO should review the record and ensure that all the above actions have been requested or completed. If the decision remains adverse to the veteran in any way, he should be furnished with a supplemental statement of the case which summarizes the pertinent evidence, fully cites the applicable legal provisions not previously provided, and reflects detailed reasons and bases for the decision. He should then be afforded the applicable time period 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 action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. CHARLES E. HOGEBOOM 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 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) (1994).