BVA9503178 DOCKET NO. 93-11 454 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUE Entitlement to a permanent and total disability rating for pension purposes. REPRESENTATION Appellant represented by: American Red Cross ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel REMAND The veteran had active service from October 1954 to November 1956. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. During the development of this case by the RO, the United States Court of Veterans Appeals (Court) has decided several cases which impact significantly on the issue of nonservice-connected pension. In Roberts v. Derwinski, 2 Vet.App. 387, 390 (1992), the Court held that each disability in a pension case must be assigned a percentage rating, that the RO should discuss the diagnostic codes used in denying a claim, that a rating decision may not be based on an examination that was conducted before all relevant evidence was gathered, and that the effect of pain on employability must be addressed. In Brown v. Derwinski, 2 Vet.App. 444, 446-47 (1992), the Court held that a pension claim must be considered under both the average person standard and the unemployability standard. See also 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. §§ 3.321, 4.17 (1993). The RO's decisions are deficient relevant to the points addressed in the above-cited cases. The evidence of record includes a report of psychiatric examination apparently in 1992 by Nelsa Rodriguez Cespedes, M.D., expressing the opinion that the veteran was incapacitated from any type of gainful employment because of his psychiatric symptomatology. Findings included persecutory ideation and auditory hallucinations. However, when the veteran was accorded a psychiatric examination by VA in October 1992, it was stated he was not hallucinating, albeit his mood was extremely anxious and somewhat depressed. A social and industrial survey conducted by VA in November 1992 found no evidence of abnormal behavior or aggressive episodes. The Board believes that more current information would be helpful in providing a clearer picture of the veteran's psychiatric status and overall medical condition. In view of the foregoing and the Board's duty to assist the veteran in the development of facts pertinent to his claim, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and obtain the names, addresses, approximate dates, and locations of all treatment received for any of his various disabilities in the recent past. After obtaining any necessary authorization, the RO should obtain and associate with the claims folder all such medical records. The RO should ensure, should it be indicated, that all records obtained be translated into English. 2. The RO should schedule the veteran for a psychiatric examination and a general medical examination to assess the nature, severity and manifestations of all disabilities that may be present. All indicated tests should be conducted and all examinations should contain diagnoses. Each examiner should include an employment history and render an opinion as to what effect the disabilities found have on the veteran's ability to work, including a Global Assessment of Functioning (GAF) Scale score with a narrative explanation of its meaning in the case of the psychiatric examination. The likelihood of improvement with treatment for the diagnosed disabilities should be noted. It is imperative that the examiners review the entire claims folder in connection with the examinations. 3. When the requested developments have been made, the case should be reviewed by the RO, and a rating decision prepared, listing all the veteran's disabilities and the percentage evaluation assigned for each disability, utilizing the standards of the VA's Schedule for Rating Disabilities as required under 38 C.F.R. § 3.321 (1994). 4. Following completion of the paragraphs above, the RO should review the evidence and determine whether the veteran's claim of entitlement to a permanent and total rating for pension purposes may now be granted, utilizing the two standards (i.e., the average person and unemployability standards) under 38 C.F.R. §§ 3.321, 4.15 and 4.17 (1994)). Thereafter, if the benefit sought on appeal is not granted, he and his representative should be provided with a supplemental statement of the case that includes the provisions of the appropriate diagnostic codes and a discussion of their appplicability to the veteran's disabilities. The appropriate response time should be allowed. The case should then be returned to the Board after compliance with all regulatory appellate procedures, if otherwise noted. No action is required of the veteran until he is so informed. The Board intimates no opinion as to the ultimate decision warranted in this case, pending completion of the requested development. 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) (1993).