BVA9505386 DOCKET NO. 93-13 443 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from April 1970 to January 1972. This appeal arises from a December 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. REMAND Service connection for post traumatic stress disorder (PTSD) requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). In this regard, the record shows that the United States Army and Environmental Support Group (ESG) advised in a November 1992 letter that it was unable to verify the veteran's stressors due to a lack of specificity in the documents provided. The ESG, however, provided information concerning combat operations by the veteran's unit in Vietnam, as well as suggestions for obtaining more specific information for the purpose of verifying the veteran's alleged stressors. In light of this evidence the Board finds further development warranted for two reasons. First, the veteran should be asked to provide more specific information. In this respect, the veteran should take notice of the fact that the United States Court of Veterans Appeals has held that asking the veteran to provide the underlying facts, i.e., the names, dates and places of the claimed events, does not constitute either an impossible or an onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). Secondly, further development is warranted because it does not appear that the RO has taken any steps to help the veteran verify his stressors by use of the alternative means suggested by the ESG. In this regard, the veteran’s claim for service connection is well grounded, hence triggering the VA’s duty to assist. The Board next observes that the veteran has been diagnosed with PTSD on numerous occasions. These diagnoses, however, all appear to have been based on a history which has yet to be verified. As an examination based on a questionable history is inadequate for rating purposes, West v. Brown, 7 Vet.App. 70, 78 (1994), it is necessary that the veteran be provided an examination where the examiner has the accurate history of the veteran’s military service. Therefore, further development is warranted. Finally, the Board notes that the veteran reports receiving Social Security benefits as a result of PTSD. While some of the medical records which underlie such an award appear to be of record, all of the records are not currently included in the veteran’s claims folder. Accordingly, these records should be secured for the Board’s review and the medical examiner’s consideration. Murincsak v. Derwinski, 2 Vet.App. 363 (1992) Therefore, this case is REMANDED for the following action: 1. The RO should contact the veteran and request that he provide the names and addresses of any health care providers, other than VA who have treated him for a psychiatric disability, to include PTSD and specify the approximate dates of treatment, if possible. Then after obtaining any necessary authorization, the RO should request and associate with the claims file copies of the complete treatment reports from sources identified by the veteran not previously secured. 2. The RO should contact the Social Security Administration and request that they furnish photocopies of all medical records pertinent to the veteran's award of disability benefits. If medical evidence utilized in processing such claim is not available, that fact should be entered in the claims file. 3. The RO should request from the veteran a statement containing as much detail as possible regarding any and all stressful events to which he was exposed in service. The veteran should be asked to provide specific details of the claimed stressful events during service, including dates, places, detailed descriptions, units of service, duty assignments, as well as the names, ranks, unit of assignment and any other identifying information concerning other individuals involved in the events. The RO should also request that the veteran provide additional information concerning the death of his brother, including military service information if his brother died in combat in Vietnam. 4.. After obtaining the forgoing requested information, the RO should forward it to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150. Any information obtained is to be associated with the claims folder. 5. Following the receipt of the ESG’s report, and the completion of any additional development warranted or suggested by that office, the RO should prepare a report detailing the nature of any combat action, or inservice stressful event, 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. 6. 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 veteran. 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 psychiatric disorder which may be present. All indicated studies, including post-traumatic stress disorders 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 or not the veteran has PTSD due to an inservice stressor the examiner is hereby notified that only the verified history detailed in the reports provided by the ESG and/or 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 and/or the RO's report is responsible for that conclusion. Any and all opinions expressed must be accompanied by a complete rationale. 7. 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 was based on the verified history provided by the ESG and/or the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the Court has held that a diagnosis of PTSD, related to service, which is based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 8. After undertaking any additional development deemed appropriate, the RO should readjudicate the issue of entitlement to service connection for PTSD. If the benefit requested on appeal is not granted to the veteran's satisfaction, the RO must issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise 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).