BVA9504553 DOCKET NO. 93-13 881 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for an amputation of the left leg. 2. Entitlement to an increased rating for post-traumatic stress disorder, currently rated 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Mark J. Swiatek, Counsel REMAND The veteran had active duty during the Vietnam era. This matter comes before the Board of Veterans' Appeals (Board) from a November 1991 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. Regarding service connection for an amputation of the left leg, the Board observes that the claim has been adjudicated without benefit of a medical opinion regarding the claimed relationship between the veteran's post-traumatic stress disorder (PTSD) and the self-inflicted gunshot wound. The veteran testified regarding the circumstances that led to the gunshot wound in February 1989. With respect to an increased rating for PTSD, the Board observes that the most recent VA psychiatric examination of March 1993 provides very little data concerning the effects of the PTSD on the veteran's initiative, efficiency and reliability levels. Additionally, subsequent medical evidence, including a statement dated in July 1993 from Dr. Santiago, a VA staff psychiatrist, clearly indicates a worsening of the PTSD symptoms subsequent to the March 1993 examination. This case was received at the Board in June 1993. In July and September 1993, additional documents pertinent to the matters at issue were added to the records assembled for appellate review. The veteran claimed that he is entitled to a total disability rating. This matter has not yet been addressed by the RO. The Board observes that the veteran is in receipt of combined rating of 90 percent for service-connected disabilities, principally the residuals of multiple shell fragment wounds. No waiver was received with respect to this evidence. 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 RO for the following development: 1. The veteran should be provided with an application for increased compensation based on individual unemployability due to service- connected disability. He should be requested to give his employment history for the last 5 years and to clarify his current employment status, specifying the amount of time he has lost from work in the recent past due to his service-connected disabilities. He should also be requested to identify all sources of recent treatment for his service-connected psychiatric disability. With any necessary authorization from the veteran, the RO should attempt to obtain copies of all indicated records which have not been previously secured. 2. With any necessary authorization from the veteran, the RO should contact the Hammond Police Department, 5925 Calumet Avenue, Hammond, IN 46320 and request all records relating to the investigation of the veteran's self-inflicted gunshot wound on February 20, 1989. 3. Following completion of the above development, the veteran should be accorded a VA psychiatric examination to determine the severity of the PTSD and the role it played, if any, in the February 1989 self-inflicted gunshot wound which resulted in the left below-the-knee amputation. The claims folder must be made available to the examiner prior to the evaluation so that the examiner may review the pertinent historical data contained therein in order to obtain a true picture of the progress of the veteran's psychiatric dis- order. The examination should be comprehensive enough to determine the nature and extent of all psychiatric symptoms. Any relationship between the PTSD and any other psychiatric disorder or substance abuse disorder should be identified. The psychiatrist should utilize any psychological testing deemed pertinent in making a complete diagnostic evaluation and in differentiating the PTSD symptoms from those attributable to other conditions. Based upon a review of the record and the examination, the physician should provide a Global Assessment of Functioning (GAF) scale code and discuss the meaning of the GAF scale code assigned. In addition, the examiner should also discuss the impairment of the veteran's ability to establish and maintain relationships as well as the reduction in initiative, efficiency and reliability levels which may be attributable to the PTSD (as distinct from impairment attributable to other conditions). Finally, the examiner should provide an opinion regarding the role that PTSD played in the self-inflicted gunshot wound of February 1989. 4. When the above development has been completed the RO should readjudicate the veteran's claim. If it has not been rendered moot, the claim for a total rating based on individual unemployability on account of service-connected psychiatric disability should also be adjudicated. The rating should reflect consideration of the applicability of the provisions of 38 C.F.R. §§ 3.321(b)(1), 3.340, 3.341 and 4.16(a). If any benefit sought on appeal is not granted to the veteran's satisfaction, a supplemental statement of the case addressing all issues in appellate status should be prepared and furnished to the veteran and his representative. They should be provided the applicable period in which to respond. Thereafter, in accordance with the proper appellate procedures, the case should be returned to the Board for further appellate review, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. GARY L. GICK 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 deter- mination. 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. 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).