BVA9506298 DOCKET NO. 92-04 828 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for residuals of a back injury. 2. Entitlement to service connection for a disorder manifested by chest pain. 3. Entitlement to an increased (compensable) evaluation for defective hearing. 4. Entitlement to an increased (compensable) evaluation for degenerative changes in the right shoulder. 5. Entitlement to an increased (compensable) evaluation for presbyopia with primary optic atrophy in the left eye. 6. Entitlement to an increased (compensable) evaluation for hypertension. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. D. Hayden, Counsel INTRODUCTION The veteran performed active duty from September 1967 to September 1968 and from January 1971 to January 1990. This matter has come before the Board of Veterans' Appeals (Board) on appeal from an April 1991 rating decision by the Department of Veterans Affairs (VA), Columbia, South Carolina, Regional Office (RO). In January 1993, this case was remanded for further development and it has been returned to the Board. REMAND In its prior remand, the Board requested additional development of the evidence in this case, which, in part, required the veteran's cooperation. He has not fully cooperated, so some of the necessary development, such as obtaining private medical records, could not be accomplished. However, the Board also asked that the veteran be given an orthopedic examination and that the claims file be made available to the examiner. Although the veteran has been examined twice since then, the claims folder apparently was not made available to the examiner on either occasion. Since the veteran is claiming service connection for a back disorder that he believes is related to a motor vehicle accident in service, the service medical records reflect back complaints, and the opinion of December 27, 1991 from Dr. Margalit was important that the orthopedic examiner review the file before expressing an opinion as to the relationship, if any, between the veteran's current back problems and service. Accordingly, it is necessary to remand the case for another examination that includes a review of the veteran's claims folder. Since that action is necessary, the veteran will be afforded another opportunity to provide the information pertinent to his claim. Therefore, this case is REMANDED for the following: 1. The veteran should be permitted to submit or identify any evidence pertinent to any of the issues on appeal. Such evidence might include recent treatment records (from VA, private or service department health care providers) pertinent to the disabilities at issue. The RO should assist in obtaining evidence identified. 2. The veteran should again be requested to provide full details of the June 1988 motor vehicle accident, including the location of the accident and information about any examination or treatment following the accident until he was seen at a military facility in late June. He should also be asked to identify any health care providers, other than G. G. Margalit,. M.D., by whom he was seen after the accident. Based on information provided by the veteran, the RO should request copies of his medical records. Regardless of whether the veteran responds, the RO should attempt to obtain from the National Personnel Records Center any records pertaining to the accident, such as police reports and reports of any line-of-duty investigation or determination. The veteran should be advised that his cooperation is required to fully develop the record in his case. 3. The veteran should be asked to identify any physicians or other medical care providers by whom he was seen for injuries sustained in motor vehicle accidents in 1992 and 1993. With his consent, copies of his medical records should be obtained. 4. With the veteran's authorization, the RO should ask Dr. Margalit to provide legible copies of the veteran's complete medical records, X-ray films, and the actual results obtained from computer- assisted tomography and magnetic resonance imaging studies. The X-ray films will be returned to Dr. Margalit after the veteran's case is finally decided. If Dr. Margalit does not have some of the above items but indicates where they can be obtained, the RO should request them. 5. When the foregoing items have been obtained, the veteran should again be examined by a specialist in orthopedics, preferably one who has not previously examined him, to determine the nature and etiology of any back disorder. Any indicated diagnostic studies, including imaging studies, should be accomplished. The examination must be conducted in accordance with the Physician's Guide for Disability Evaluation Examination. The claims folder, as supplemented by any records, X-ray films, etc., obtained pursuant to the instructions above, and a separate copy of this remand must be made available to the examiner for his or her review prior to the examination. The examiner should be requested to express an opinion regarding any relationship between the veteran's current back disorder and the 1988 automobile accident and documented back complaints during service. 6. The Board observes that there was a degradation of the veteran's auditory acuity between the audiometric examinations conducted in June 1991 and August 1993 and that an early cataract was noted in the left eye when the veteran was examined by the VA in May 1990. The veteran should be given current audiometric and ophthalmologic examinations. The examining ophthalmologist should be requested to express an opinion, if possible, as to the etiology and length of duration of any cataract found. The claims folder and a separate copy of this remand must be made available to the ophthalmologist. Following completion of the foregoing, the RO must review the record and ensure that the foregoing development has been completed to the extent possible. If any development, that can be completed, is incomplete, appropriate corrective action should be implemented. Thereafter, all of the evidence should be reviewed and the case should be readjudicated by the RO, including consideration of 38 C.F.R. § 3.158(a) (1994). If the benefits sought on appeal are not granted, the veteran and his representative should be furnished a supplemental statement of the case and afforded a suitable opportunity to respond. Thereafter, the case must be returned to the Board in accordance with the law and regulations regarding the processing of appeals. No further action is required of the veteran until he receives further notice. By this remand, the Board intimates no opinion regarding the decision warranted, pending completion of the requested development. Action on the remaining issues will be deferred until the development has been accomplished and the case is returned to the Board. (Continued on next page) JANE E. SHARP 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).