BVA9502140 DOCKET NO. 92-07 801 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. S. Nemeth, Associate Counsel INTRODUCTION The veteran's active service extended from July 1970 to February 1972. This matter was previously before the Board of Veterans' Appeals (Board) in December 1992, at which time the Board remanded the case for further development. The case originally came to the Board on appeal from a September 1989 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which denied the veteran's claim for service connection for PTSD. REMAND The veteran contends that he currently has PTSD as a result of his service in Vietnam. He contends that his PTSD was caused, in large part, by being in the proximity of an ammunition dump explosion which, in addition to frightening him, caused small pieces of shrapnel to strike, but not injure him. In a December 1992 decision, the Board remanded the case for further development. The RO was to request further detailed information from the veteran regarding his claimed stressors; it was to request information from the Environmental Support Group (ESG) which may corroborate the veteran's stressors; it was to conduct a social and industrial survey to include interviewing the veteran, family members, co-workers, and members of the community; and it was to schedule a hospitalization of the veteran in order to obtain correct diagnoses of the veteran's psychiatric disorder. The RO wrote to the veteran in January 1993, at his last known address, a halfway house in San Fernando, California, to request further evidence from him. The letter was returned to the RO in March 1993, marked "attempted unknown." The record also shows that a letter mailed to the same address, was returned to the RO, marked "moved, left no address" in February 1992. However, a letter to the veteran dated May 1992, mailed to the San Fernando address, appears to have been delivered, as there is no returned letter and envelope attached to the claims folder. No new address is contained in the claims file. A field examination report dated in February 1993 shows that the VA field examiner had visited the veteran's last known address and was informed that the veteran had moved out over a year prior to the field examiner's visit. The field examiner spoke to the operator of the halfway house where the veteran had lived. The operator of the house would not furnish a new address to the examiner but did offer to give the veteran the examiner's card when he saw him at a Narcotics Anonymous meeting, along with the message that the RO needed to speak with him in order to assist in the adjudication of his claim. There is no evidence in the records that the RO followed up with the operator of the halfway house to determine if indeed the card and message were passed along to the veteran or whether there were any attempts to visit the Narcotics Anonymous meetings. Likewise, there is no evidence that the social and industrial survey was completed, nor is there any reason given as to why it was not completed. The VA has a duty to assist the veteran to develop his case and the RO failed to fulfill this duty by not completing the social and industrial survey. As the completion of the social and industrial survey may provide highly probative evidence as to both the veteran's condition and his whereabouts, the RO should arrange to have the social and industrial survey completed, to include a follow-up with the operator of the halfway house. The RO sent a request to the ESG in August 1993, based on the information that existed in the claims file. The ESG responded in September 1993 with a report consistent with the veteran's claimed stressor. The ESG also requested more detailed information from the veteran so that it could perform further research into the veteran's claimed stressors. Should the veteran be located, the RO should ask the veteran to supply the additional information requested by the ESG. If not located the RO should attempt to gather the information requested to the extent possible. As of April 1994, the RO had not heard from the veteran and subsequently asked the Disabled American Veterans (DAV) if they had a current address for the veteran. The DAV responded in October 1994 and informed the RO that it had sent a letter to the veteran in April 1994 which was returned as undeliverable. The DAV further stated that it had no current address. The RO should inquire as to whether the DAV has since learned of the veteran's whereabouts. Due to the unknown whereabouts of the veteran, the Board's December 1992 Remand order for the veteran to be hospitalized and examined, did not occur. Should the veteran be located, the RO should make arrangements to complete the required medical evaluations. If the veteran still cannot be located, the entire claims folder should be made available to a VA psychiatrist for an opinion on whether or not the veteran has PTSD. The Board understands that the presence of the veteran was necessary to complete the Board's entire December 1992 Remand order. However, in order to fulfill its duty to assist, the RO could have and should have completed the social and industrial survey. Since only marginally more evidence has been added to the claims file since the Board's prior Remand and because there is still not enough definitive evidence to fairly adjudicate the case on its merits, this case should be remanded to the RO for the following development: 1. The RO should contact the veteran's representative, the DAV, to determine if they have had any recent contact with the veteran, if they have obtained a current address for him, or if they have a means by which to contact him. If so, the RO should obtain such information. 2. The RO should complete a social and industrial survey or field investigation to determine the veteran's whereabouts. It should be ascertained if the veteran is working. Family members (specifically the veteran's brother with whom the veteran previously lived), former coworkers, members of the community (to include the operator of the halfway house and fellow members of Narcotics Anonymous, if possible) and the veteran, if located, should be interviewed. The field examiner should follow any leads regarding the veteran's whereabouts and should inform those people interviewed that the information is requested solely to adjudicate the veteran's claim for benefits. 3. If the veteran is located, the RO should proceed with the following development: A. The veteran should be contacted and requested to provide a detailed statement containing verifiable information regarding the events claimed as "stressors" during his military service. The veteran should be asked to provide specific details about the events such as his unit designation, unit location, combat service dates, number and names of casualties, and other units involved, if known. He should be told that the information is necessary to obtain supportive evidence and that failure to cooperate could result in an adverse decision. The information should then be forwarded to the ESG as previously requested. B. Subsequently, in order to obtain clear medical diagnoses, the RO should schedule the veteran for a period of hospitalization for purposes of observation and evaluation. Again, the veteran should be told that the information is necessary to obtain supportive evidence and that failure to cooperate could result in an adverse decision. The veteran should be examined by a panel of two VA psychiatrists who have not previously examined him to determine the exact diagnosis, if any, of his current psychiatric disorder. The entire claims folder and a copy of this remand must be made available to and be reviewed by the examiners prior to the examination. Each psychiatrist should conduct a separate examination with consideration of the criteria for PTSD. The examination report should include a detailed account of all pathology found to be present. The psychiatrists should also render an opinion as to whether the symptoms or behaviors reported in service represented a neuropsychological disorder(s) and whether or not the veteran's drug use, beginning in service, was a result of an acquired psychiatric disorder(s). If there are psychiatric disorders other than PTSD, the panel 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 so specified. If a diagnosis of PTSD is appropriate, the examiners should specify the credible "stressors" that caused the disorder and the evidence upon which they relied to establish the existence of the stressor(s). They should also describe which stressor(s) the veteran re-experiences and how he re-experiences 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 current edition of the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder. C. The RO should review the aforementioned examination report and determine if it is adequate for rating purposes and in compliance with this Remand. If not, the report should be returned for corrective action. 4. If the veteran is not located, the RO should arrange to have a VA psychiatrist examine the entire claims folder and render an opinion regarding whether or not, based on all records on file, it can be reasonably said that the veteran has PTSD. The report should include a complete rationale for all opinions expressed. 5. The RO should review the aforementioned opinion report and determine if it is adequate for rating purposes and in compliance with this Remand. If not, the report should be returned to the psychiatrist for corrective action. Following the completion of these actions, the RO should review the veteran's claim and if the decision remains unfavorable, the veteran and his representative should be provided with a supplemental statement of the case and be afforded a reasonable period of time in which to respond. Thereafter, the case, in accordance with the current appellate procedures, should be returned to the Board for completion of appellate review. No further action on the part of the veteran is required until further notice. JOAQUIN AGUAYO-PERELES 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) (1993).