BVA9507983 DOCKET NO. 93-16 785 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a permanent and total disability evaluation for pension purposes. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. M. Flatley, Counsel REMAND The veteran had active service from March 1975 to March 1976. This case came before the Board of Veterans' Appeals (Board) on appeal from a March 1992 rating decision of the Columbia, S.C., Department of Veterans Affairs (VA) regional office (RO). Review of the record indicates that the veteran has submitted a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). The VA therefore has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78, 81-82 (1990). In this regard, the record establishes that the veteran is in receipt of benefits administered by the Social Security Administration. A November 1989 decision from that agency reflects that several private medical reports were considered in its determination; such reports are not of record. In addition, the report indicates that the veteran received outpatient treatment at a mental health facility from 1983 until shortly before the determination. The Board also notes that a 1989 report of a private psychiatric evaluation includes a diagnosis of paranoid schizophrenia and notes the possibility of post-traumatic stress disorder or organic brain syndrome superimposed on schizophrenia. The veteran's most recent VA special psychiatric examination was conducted in 1988, and the last general VA examination, conducted in September 1992, included a diagnosis of history of chronic paranoid schizophrenia; a history of head trauma was also noted, associated with the veteran's reported skull fracture. At his personal hearing, the veteran described continuing psychiatric symptomatology. In this case, evaluations have been assigned disabilities described as anxiety disorder with some depression, and residuals of a broken right forearm and wrist. Additional clinical findings are of record, referable, for example, to removal of a cyst on the left side of the neck, and to forehead scars; further detail is essentially absent, and evaluations have not been assigned. In addition, it appears that generally, additional clinical data may prove helpful in the evaluation of the veteran's claim. The Board notes that the United States Court of Veterans Appeals (Court) has held that each disability in a pension case must be assigned a disability rating; a discussion of the pertinent diagnostic codes used in denying a claim must be made and the determination must be made only after all pertinent evidence is gathered. Roberts v. Derwinski, 2 Vet.App. 387 (1992). As noted above, the record in this instance indicates that disabilities may be present for which a rating has not been assigned. Further, the Court has held that a claim for pension benefits must be considered under both the average person and unemployability standards. 38 U.S.C.A. § 1502(a) (West 1991); Brown v. Derwinski, 2 Vet.App. 444 (1992); 38 C.F.R. §§ 3.321, 4.15, 4.17 (1994). Overall, in order to fully assist the veteran in the development of his case and extend to the veteran every equitable consideration, the Board concludes that additional development is warranted. This case is therefore REMANDED for the following: 1. After any necessary information and authorization are obtained from the veteran, duplicates of pertinent recent treatment, VA or private, inpatient or outpatient, associated with the veteran's claimed disabilities, particularly his psychiatric disability, should be obtained by the RO and incorporated into the claims folder. 2. The RO should obtain from the Social Security Administration the remaining records pertinent to the veteran's claim for Social Security disability benefits, particularly the medical records relied upon by the Administration in reaching its favorable determination. 3. A special VA psychiatric examination should be arranged to determine the extent and severity of the veteran's psychiatric disorder. The examination should be conducted in accordance with the pertinent provisions of the VA's Physician's Guide for Disability Evaluation Examinations. The examination report should include a detailed description of the veteran's symptoms, clinical findings, and associated functional impairment; each psychiatric disorder present should be identified and described as above. All indicated studies should be done. The examiner should assign a Global Assessment of Functioning Score (GAF) and should explain the meaning of the numerical score assigned. A comprehensive report, which includes the examiner's conclusions and the foundation upon which they are based, as well as the history of the veteran's disability, should be provided and associated with the veteran's claims folder. The veteran's claims folder should be made available to the examiner for review prior to the examination. 4. A special VA neurologic examination should be scheduled to determine whether any residual disability associated with the veteran's claimed history of a skull fracture is present. The examination should be conducted in accordance with the VA's Physician's Guide for Disability Evaluation Examinations. All indicated studies should be conducted in order to clearly identify any disease entity. The examination report should include a full description of any symptoms, clinical findings, and associated functional impairment; a full description of the veteran's residuals scars should be provided, as set forth in the Physician's Guide. All findings should be recorded in detail and any disorder present should be clearly identified. A comprehensive report, with attention to the aforementioned, should be provided. The veteran's claims folder should be provided to the examiner for review prior to the examination. 5. The RO should then review the veteran's claim; each disability identified should be rated. All pertinent law, regulations, and Court decisions, particularly Roberts and Brown, noted above, should be considered. If the veteran's claim remains in a denied status, he and his representative should be provided with a supplemental statement of the case, which includes all pertinent law and regulations and a full discussion of action taken on the veteran's claim, consistent with the Court's instruction in Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The applicable response time should be allowed. The case should then be returned to the Board, if in order, after compliance with customary appellate procedures. 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. THOMAS J. DANNAHER 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. 133-446, § 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) (1994).