Citation Nr: 0002776 Decision Date: 02/03/00 Archive Date: 02/10/00 DOCKET NO. 97-29 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Associate Counsel INTRODUCTION The veteran served on active duty from May 1966 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, in which the RO denied the veteran's claim seeking entitlement to service connection for post- traumatic stress disorder (PTSD). The claim was remanded by the Board in June 1999 in order to afford the veteran a hearing, which was subsequently held in November 1999. FINDING OF FACT The claims file does not contain competent evidence that the veteran has PTSD. CONCLUSION OF LAW The veteran's claim of entitlement to service connection for PTSD is not well grounded. 38 U.S.C.A. §§ 1155, 5107 (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION The veteran asserts that he has PTSD as a result of his service. In May 1996, the RO denied the veteran's claim of entitlement to service connection for PTSD. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). If a condition noted during service is not shown to be chronic, then generally a continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under he court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded or reopened on the basis of 38 C.F.R. § 3.303(b) if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). The initial question in this case is whether the veteran has presented a well grounded claim for service connection. In this regard, the veteran has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded;" that is, the claim must be plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). To establish that a claim for service connection is well grounded, a veteran must demonstrate a medical diagnosis of a current disability; medical, or in certain circumstances, lay evidence of inservice occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an inservice disease or injury and the current disability. Where the determinative issue involves medical causation, competent medical evidence to the effect that the claim is plausible is required. See Epps v. Gober, 126 F.3d 1464 (1997). Applicable regulations provide that service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125, a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (1999). The veteran's discharge (DD Form 214) shows that his military occupation specialty was administrative specialist. The veteran's personnel record (AF-7) shows that the veteran served with the U.S. Air Force, with service from August 1968 through September 1969 in Guam as a classified document distribution clerk. The veteran asserts that service connection for PTSD is warranted based on his service as a classified document distribution clerk in Guam, which he argues subjected him to a great deal of stress. Specifically, he testified that he handled classified message traffic, and that "I was totally stressed out because I always said if I made a mistake and sent it to the wrong agency something bad could happen." As for combat status, the service decorations listed in the veteran's DD Form 214 do not include the Purple Heart, or similar combat citation. 38 C.F.R. § 3.304(f). However, under 38 U.S.C.A. § 1110, the veteran must submit proof of a presently existing disability resulting from service in order to merit an award of compensation. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). In this case, the veteran's claim must be denied because he has not provided a medical opinion to substantiate his claim that he has PTSD. The veteran's service medical records show that he was treated for "nervousness x 3 weeks" in 1969. The veteran's separation examination report, dated in February 1970, shows that his psychiatric system was clinically evaluated as normal. Service medical records are otherwise silent as to complaints, treatment or a diagnosis involving an acquired psychiatric disorder. As for the post-service medical evidence, VA outpatient treatment records from the VA Medical Center in Los Angeles, dated between 1996 and 1997, include a report dated in October 1997 which shows that the veteran was treated for what was diagnosed as schizophrenia, paranoid type, "status post alcohol and cannabis," and tobacco abuse. He was noted to have a history of paranoid schizophrenia, with the last hospitalization about four years ago. Other diagnoses in the VA outpatient treatment reports include three notations of "rule out PTSD." In March 1996, the veteran was afforded a VA psychiatric examination. A review of the examination report shows that the Axis I diagnoses were history of chronic paranoid schizophrenia, and "history of alcohol and cannabis abuse in past." A VA PTSD examination report, dated in January 1998, contains Axis I diagnoses of schizophrenia, chronic paranoid type, rule out schizo-affective disorder, and alcohol dependence, sustained in full remission. The claims file does not currently contain a clear diagnosis of PTSD. Accordingly, as no competent evidence has been presented that the veteran currently has PTSD, his claim must be denied as not well grounded. See 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.304(f). In this regard, the Board notes that the three notations of "rule out PTSD" are equivocal by their very terms, that they are all accompanied by unequivocal diagnoses of schizophrenia, and that they are not shown to have been based on a review of the veteran's C-file or otherwise accompanied by indicia of reliability, such as psychological testing, additional medical comment or citation to clinical findings. The Board therefore finds that the notations of "rule out PTSD" are not competent medical evidence of PTSD which are sufficient to render the claim well-grounded. The only other evidence that the veteran has PTSD are his statements. However, what is lacking to well-ground the present claim is medical evidence of a diagnosis of PTSD. The veteran, as a lay person untrained in the fields of medicine and psychiatry, is not competent to offer an opinion as to diagnosis. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In sum, the Board must conclude that the veteran's claim is not well-grounded. 38 U.S.C.A. § 5107(a). The Board notes that at his hearing, the veteran testified that he had been diagnosed with PTSD by a physician whom he identified as "Dr. DeArmas," at a VA outpatient treatment facility in Los Angeles. The VA outpatient treatment records in the claims file (which are all from the Los Angeles VA Medical Center (VAMC)) do not show that the veteran has been diagnosed with PTSD. However, the Board notes that VA has a duty to advise the veteran that should he obtain medical evidence in support of this argument, it may be sufficient to reopen his claim. See McKnight v. Gober, 131 F. 3d 1483 (Fed. Cir. 1997). As a final matter, in reaching this decision the Board considered the fact that the veteran reports that he is receiving Social Security benefits, and that he was hospitalized at a VA facility in West Los Angeles in about 1975, at a VA facility in Brentwood in about 1979, and at the "Ingleside Hospital in Rosemead," at an unspecified date, and that no attempt to secure these records was made by the RO. However, at his hearing in November 1999, the veteran testified that the only physician who has ever diagnosed him with PTSD was "Dr. DeArmas," who had treated him at a VA outpatient treatment center in Los Angeles. The veteran further testified that Dr. DeArmas' first diagnosis of PTSD came about three years ago. The veteran also stated that he did not believe that he was receiving SSA benefits due to PTSD. However, as stated previously, the VA outpatient treatment records in the claims file do not show that the veteran has been diagnosed with PTSD. The Board further notes that although the veteran testified that he was hospitalized at a VA hospital in Sepulveda, the RO requested all such medical records in November 1997, and no such records of VA hospitalization were obtained. To the extent that there may be a "duty to assist" in this case, "the 'duty to assist' is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support a claim. In connection with the search for documents, this duty is limited to specifically identified documents that, by their description, would be facially relevant and material to the claim." Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (emphasis added). There being no offer of proof showing why these records would be relevant, particularly in light of the fact that the veteran stated that his first and only diagnoses of PTSD have come from Dr. DeArmas, beginning about three years ago, the Board concludes that remanding this claim for these records would, in this case, amount to nothing more than a "wild goose chase." Such action would further represent disparate treatment favoring this veteran who has failed to meet his statutory burden. Grivois v. Brown, 6 Vet. App. 136, 140 (1994) ("[I]f the Secretary, as a matter of policy, volunteers assistance to establish well groundedness, grave questions of due process can arise if there is apparent disparate treatment between claimants in this regard.") Although the Board considered and denied this appeal on a ground different from that of the RO, the appellant has not been prejudiced by the decision. This is because in assuming that the claim was well grounded, the RO accorded the claimant greater consideration than his claim in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). To remand this claim to the RO for consideration of the issue of whether the appellant's claim is well grounded would be pointless and, in light of the law cited above, would not result in determinations favorable to him. VAOPGCPREC 16-92 (O.G.C. Prec. 16-92); 57 Fed.Reg. 49,747 (1992). Further, the Court has held that "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded analysis." Meyer v. Brown, 9 Vet. App. 425, 432 (1996). The Board views its discussion as sufficient to inform the veteran of the elements necessary to complete his application for service connection for the claimed disability. See Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995). ORDER Service connection for PTSD is denied. BRUCE KANNEE Member, Board of Veterans' Appeals