BVA9502605 DOCKET NO. 93-08 978 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from June 1966 to January 1970. This appeal arises from a June 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The RO denied entitlement to service connection for post-traumatic stress disorder. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. REMAND The veteran served on active duty in the United States Air Force as a disbursement accounting specialist. His personnel records reflect service in the Republic of Vietnam from September 1968 to January 1970, but do not reflect his participation in combat. His decorations include the Vietnam Service Medal and the Republic of Vietnam Campaign Medal. In statements on file the appellant has described his involvement in the "Tet offensive," the deaths of many comrades, mortar and rocket attacks, and his "in flight" participation with the "Third Special Operations Service." VA outpatient treatment reports on file dated in 1989 show that he was treated for psychiatric symptomatology repeatedly diagnosed as post-traumatic stress disorder (PTSD). Additionally, a VA psychiatrist diagnosed PTSD following an April 1991 special psychiatric examination. In West v. Brown, 7 Vet.App. 70 (1994), the United States Court of Veterans Appeals held that in PTSD claims based on the allegation of a combat stressor it is necessary to determine whether or not the veteran actually engaged in combat. The Court further held that an examination which relies on a history which is inaccurate is an examination which is inadequate for rating purposes. Id. at 77. Accordingly, as verification of the veteran's described stressors has never been attempted by the RO, and as additional Vet Center medical records concerning care for PTSD have not been requested, further development is warranted. Therefore, to ensure compliance with due process requirements, this case is REMANDED for the following action: 1. After obtaining any necessary authorization, the RO should request and associate with the claims file photocopies of the complete records pertaining to the veteran's treatment by Dr. Steven Staten of the Vet Outreach Center in Kailua-Kona, Hawaii. 2. The veteran should be asked to provide specific details about the stressful events he claims to have experienced in service. In this regard, the veteran should be asked to provide the precise dates and places of each claimed stressful event, as well as his unit assignment at the time of each claimed stressor. If the veteran is referring to a "Tet Offensive" other than that initiated by enemy forces in 1968, he should state when the referenced offensive took place. The veteran should further provide the names and approximate dates of death of any comrades who were killed or wounded in action. The veteran is hereby informed that the United States Court of Veterans Appeals has held that requiring a claimant to provide this information to the VA does not represent an impossible or onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 3. Thereafter, the information provided by the appellant concerning the specific circumstances of the claimed stressors and a copy of the veteran's service records should be sent to the United States Army and Joint Services Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22150, for verification of the stressors claimed by the appellant. 4. Following the receipt of the ESG’s report, and the completion of any necessary development, the RO should prepare a report detailing the nature of any combat action, or stressful event, that has been verified by the ESG. If no combat or stressor has been verified, the RO should so state in their report. This report is then to be added to the claims folder. 5. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a psychiatrist who has not previously seen or treated the appellant. 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 current psychiatric disorder, including post-traumatic stress disorder, which may be present. All indicated studies, including post-traumatic stress disorder sub scales, are to be performed. The claims file must be provided to and reviewed by the examiner prior to conducting this examination. In determining whether the veteran has PTSD the examiner is hereby notified that only the verified history detailed in the reports provided by the ESG and the RO may be relied upon. If the examiner believes that PTSD is the appropriate diagnosis the examiner must specifically identify which stressor detailed in the ESG’s or the RO’s report is responsible for that conclusion. All opinions expressed should be accompanied by a complete rationale. 6. 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 report to verify that any diagnosis of PTSD rendered by the examiner was based on the verified history provided by the ESG and the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. Again, the Court has held that a diagnosis of PTSD based on an examination which relies upon an unverified history is inadequate for rating purposes. 7. 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. If the benefit sought 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 provided. Thereafter, the case should be returned to the Board for further appellate review, if 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). The Board observes that Tet, the Vietnamese lunar year, is an annual celebratio when one speaks of the "Tet Offensive" it is generally assumed that reference is campaign launched by the Viet Cong, with the support of the North Vietnamese Arm and ending with the military defeat of those forces by February 10, 1968. See T 194-5 (J.S. Bowman, ed. 1985). The Board therefore questions the veteran’s refe in view of the fact that he was stationed in New Mexico in January and February