BVA9507293 DOCKET NO. 93-11 860 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for post traumatic stress syndrome (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. M. Lynch, Associate Counsel INTRODUCTION The veteran served on active duty from October 1943 to April 1946. This appeal arises from a September 1992 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York which denied the veteran's petition to reopen his claim of entitlement to service connection for PTSD. REMAND The veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. However, for the reasons that follow, it appears that the statutory duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a) has not yet been fully met. Service connection for PTSD requires (1) medical evidence establishing a clear diagnosis of the condition; (2) credible supporting evidence that the claimed inservice stressor actually occurred; and (3) a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). However, the evidence in this case it is not clear as to whether or not the veteran has PTSD. In support of his petition to reopen his claim, the veteran submitted a letter from J. Gregory Gorzynski, M.D. dated in April 1992 which indicated that PTSD should be considered as the diagnosis. It is not clear from Dr. Gorzynski's letter whether he has definitively diagnosed the veteran as having PTSD. The Board must base its determination on medical evidence. See Colvin v. Derwinski, 1 Vet.App. 171 (1991). Therefore, a VA examination would be useful in determining whether the veteran's current condition warrants a diagnosis of PTSD, whether stressful events in service were sufficiently grave or severe so as to cause PTSD, and whether any current symptomatology associated with PTSD is linked to the veteran's inservice stressors. See West v. Brown, 7 Vet.App. 70, 78-79 (1994). In addition, the examiners at the veteran's most recent VA examination in October 1989 diagnosed dysthymia. An opinion should also be elicited as to the probability that any dysthymia had its onset during service or was caused or aggravated by service. The Board also notes that the veteran has submitted an excerpt from an administrative law judge's decision which granted him Social Security Disability benefits. The excerpt contained a finding that he had severe PTSD. Further, a review of the record reveals that the veteran was examined by Ray Kremberg, M.D., Rita Clark, Ph.D., Robert Raymond, Ph.D. and Richard King, M.D. in conjunction with claims for Social Security benefits. These physicians have indicated that their examination reports are part of the SSA records. It has been resolved in various cases, essentially, that although the SSA decisions are not controlling for VA purposes, they are pertinent to the adjudication of a claim for VA benefits, and that the VA has a duty to assist the veteran in gathering SSA records when put on notice that the veteran is receiving SSA benefits. Collier v. Derwinski, 1 Vet.App. 413 (1991); Murincksack v. Derwinski, 2 Vet.App. 363 (1992); Masors v. Derwinski, 2 Vet.App. 181 (1992); and Brown v. Derwinski, 2 Vet.App. 444 (1992). Therefore, the RO should make arrangements to obtain all SSA records with respect to the veteran, including complete copies of all decisions granting or revoking benefits and medical reports upon which such decisions were based. A review of the record also reveals that the veteran has received treatment from several private physician's since his discharge from service, including J. Gregory Gorzynski, M.D., Fiore Trumbetta, M.D. and Arthur Phillips, M.D. However, only summaries of these physicians' treatment are currently associated with the claims folder. The veteran also received treatment at the Hudson Guild Community Service, for which there are no treatment reports of record. These complete medical records should be obtained since they could contain new and material evidence. See Ivey v. Derwinski, 2 Vet.App. 320 (1992). The RO should make arrangements to obtain the veteran's complete medical records from these physicians and should point out that the actual records, rather than summaries, are pertinent. 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 contact the veteran and request that he provide the names and addresses of all health care providers which have treated him for any psychiatric disorder since his discharge from service. The Board is particularly interested any treatment received at the Hudson Guild Community Service; from J. Gregory Gorzynski, M.D.; from Fiore Trumbetta, M.D.; and from Arthur Phillips, M.D. 2. After securing the necessary releases, the RO should obtain all treatment reports and hospital treatment folders from all private health care providers listed by the veteran that are not already on file. The RO should point out that the actual records, rather than summaries, are pertinent. The RO should also obtain any VA treatment records pertaining to the veteran. If any records are not available, that fact and the reason(s) should be annotated in the claims folder 3. The RO should make the necessary arrangements in order to obtain a complete copy of any SSA decisions granting or revoking disability benefits to the veteran, including, but not limited to, any decisions rendered in April 1986 and January 1993. The RO should also obtain all the records from the SSA that were used in considering the veteran's claim(s) for disability benefits, including any reports of subsequent examinations or treatment, including, but not limited to, reports of examination completed by Ray Kremberg, M.D.; Rita Clark, Ph.D.; Robert Raymond, Ph.D.; and Richard King, M.D. 4. Following the above, the RO should schedule the veteran for a comprehensive VA psychiatric examination to be conducted by an examiner who has never previously examined or treated the veteran to determine the diagnoses of all psychiatric disorders that are present. The entire claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. The examination report should include a detailed account of all psychiatric pathology found to be present. If there are different psychiatric disorders other than PTSD, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The psychiatrist should also furnish an opinion as to the probability that any psychiatric disorder, including dysthymia, had its onset during service or was caused or aggravated by service. With respect to PTSD, the examination report should reflect review of pertinent material in the claims folder. The examiner should integrate the previous psychiatric findings and current diagnoses to obtain a true picture of the veteran's psychiatric status. If a diagnosis of PTSD is appropriate, the examiner should specify (1) which stressor found to be established by the record was sufficient to produce PTSD; and (2) whether there is a link between current symptomatology and one or more of the inservice stressors found sufficient to produce PTSD. The psychiatrist should describe which stressor(s) the veteran reexperiences and how he reexperiences them. The report of examination should include a complete rationale for all opinions expressed. All necessary special studies or tests including psychological testing and evaluation such as the Minnesota Multiphasic Personality Inventory (MMPI) and the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorder are to be accomplished. The diagnosis should be in accordance with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised 1987). 5. The RO should review the examination report and determine if it is adequate for rating purposes and in full compliance with this remand. If not, the report should be returned to the examiner for corrective action. Once the foregoing has been accomplished, and if the benefits are not granted to the satisfaction of the veteran, both the veteran and his representative should be furnished a supplemental statement of the case covering all the pertinent evidence, law and regulatory criteria. They should be afforded a reasonable period of time in which to respond. Thereafter, the case should be returned to the Board for further appellate consideration. The veteran needs to take no action until so informed. The purpose of this REMAND is assist the veteran and to obtain clarifying information. JOAQUIN AGUAYO-PERELES Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 State. 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).