BVA9500215 DOCKET NO. 93-05 473 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to a total rating for individual unemployability due to service connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Kay F. Mayer, Associate Counsel INTRODUCTION The appellant served on active duty from September 1968 to February 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) of San Diego, California. While the issue of an increased rating for PTSD was not included in the May 1992 notice of disagreement for a total rating for individual unemployability due to service connected disabilities, the representative did indicate disagreement with the rating of 50 percent for her service connected PTSD at the September 1992 hearing. The Board has interpreted that hearing testimony as a notice of disagreement with grant of a 50 percent rating for PTSD. The issue was addressed in the Hearing Officer's decision, and in a supplemental statement of the case. REMAND The Board has noted that VA hospitalization records for the appellant for treatment of her psychiatric pathology dated in December 1993 and in April 1994 have recently been incorporated in the record. The appellant, however, has not waived consideration of those records by the RO in making a determination of her claim. Therefore, in the absence of a waiver from the appellant of consideration of these newly submitted records by the RO, the Board concludes the RO should consider this new evidence with respect to the issues before the Board and make a determination. 38 C.F.R. § 20.1304(c) (1993). Moreover, the Board finds that the appellant should undergo a further VA psychiatric examination in light of these newly submitted treatment records for psychiatric pathology, her testimony at the September 1992 hearing that she has been unable to maintain employment beyond very brief periods on her last several jobs, and her representative's contentions that she was unable to obtain and maintain employment. Also, the appellant's records of VA outpatient psychiatric treatment since January 1992 that are not currently of record should be obtained and associated with the claims file. The records recently added to the claims file show treatment by a doctor at the Mission Valley Clinic. The VA has a duty to assist a veteran in developing facts pertinent to a potentially well-grounded claim. 38 U.S.C.A. § 5107(a) (West); 38 C.F.R. § 3.159 (1993). That duty includes obtaining medical records and medical examinations where indicated by the facts and circumstances of an individual case. See Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App. 90 (1990). Also, a social and industrial survey should be obtained. She is also service connected for a scar on the left flank that should be examined. To ensure that the (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 regional office (RO) for the following development: 1. The RO should obtain the names and addresses of all medical care providers, including VA facilities, where the veteran has been treated for any psychiatric disorder or for her left flank scar since January 1992. After securing any necessary release, the RO should obtain these records. If no records are found, the claims folder should reflect the attempts made to obtain the records and the appellant and her representative should be notified of the negative results. 38 C.F.R. § 3.159. 2. The veteran should be afforded a VA psychiatric examination to determine the nature and extent of her service-connected PTSD and any other psychiatric disorders, including an opinion of the extent of the industrial impairment caused by the service-connected disorder and any other psychiatric disorder. All appropriate studies indicated, including psychological testing should be performed. The examiner should offer an opinion as to the appellant's global assessment of functioning (GAF) score. The claims folder should be made available to the examiner for review before the examination. 3. The veteran should also undergo an examination of her other service connected disorder, the scar on the left flank. All indicated tests should be performed and all clinical findings should be reported in detail. The claims folder should be made available to the examiner for review prior to the examination. 4. The appellant should be afforded a VA social and industrial survey to assess her employment history and day to day functioning. A written copy of the report should be inserted into the claims folder. 5. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. When this development has been completed the case should be returned to the Board for final appellate consideration, if otherwise in order. No action by the appellant is required until she receives further notice. The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this case, pending completion of the requested development. MICHAEL D. LYON 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).