BVA9504562 DOCKET NO. 93-10 903 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had active service from December 1963 to November 1965. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which granted service connection for post-traumatic stress disorder and assigned a 10 percent disability rating. A review of the evidence of record discloses that service connection is in effect for neurodermatitis of the lower extremities with tinea pedis and tinea cruris, rated as 10 percent disabling. The veteran's notice of disagreement with regard to the assignment of the 10 percent rating for his post- traumatic stress disorder which was received in September 1992 also reflected that he was disagreeing with the 10 percent rating assigned for his skin disorder. He stated that he had been told by a VA dermatologist that he had chloracne, a condition "rated under Agent Orange." In an October 1992 communication he was informed that a claim for an increased evaluation for his skin disorder was last reviewed by the Board in November 1991. He was informed that he could reopen his claim at any time by furnishing medical evidence showing that his skin disorder had increased in severity. The RO stated that it had not received new regulations pertaining to disabilities based on Agent Orange exposure. The RO stated it would make the decision as soon as possible after the regulations were received. The Board notes that the regulations have now been revised and diseases associated with exposure to certain herbicide agents are now enumerated in 38 C.F.R. § 3.309(e) (1993), the most recent version of which is published at 59 Fed. Reg. 5107 (1994). Additional proposed amendments have been published at 59 Fed. Reg. 5161 (1994). Further, the Secretary of the Department of Veterans Affairs formally announced in the Federal Register, on January 4, 1994, that a presumption of service connection based on exposure to herbicides used in Vietnam was now warranted for specified conditions, or for "any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted." 59 Fed. Reg. 341 (1994). Supplemental information consisting of a discussion of the scientific and medical evidence relied upon in support of the final regulations follows the formal declaration. 59 Fed. Reg. 341-346 (1994). Therefore, claims for service connection for disabilities based on exposure to Agent Orange may now be adjudicated. See VBA Circular 21-94-1 (Feb. 15, 1994). In order to ensure due process of the veteran's claim, the RO must have the opportunity to review the veteran's claim for service connection for disabilities claimed as residuals of Agent Orange exposure, including chloracne and peripheral neuropathy. REMAND The veteran has not been accorded a rating examination by VA since December 1990. Evidence of record indicates that a psychiatric examination scheduled for the veteran by VA in December 1992 was canceled because he was a VA employee. Another psychiatric examination was scheduled for January 1993, but it was also canceled, this time because of "undelivered notification." The veteran apparently was employed at the VA Medical Center, Tuskegee, Alabama, and his correct mailing address should be available. In his informal hearing presentation dated in July 1993, the veteran's accredited representative asked that the veteran be accorded a thorough and contemporaneous examination. The Board also notes that, at the time of the personal hearing held before a hearing officer at the RO in December 1992, the veteran testified that he was seeing a physician twice a month and a psychologist once a month for psychiatric purposes. Testimony was also given that his medication had recently been increased. Additionally, the veteran reported missing significant time from his job with the Supply Service of the VA Medical Center, Tuskegee, Alabama, throughout the past several years. However, the most recent medical evidence which is of record is dated in 1991. VA has a duty to assist the veteran in the development of facts pertinent to his claim under 38 C.F.R. § 3.103(a) (1994). The United States Court of Veterans Appeals (Court) has held that fulfillment of the VA's duty to assist the veteran includes the procurement and consideration of any relevant medical records. Ferraro v. Derwinski, 1 Vet.App. 326, 334 (1991). Additionally, the Court has held that the duty to assist includes providing the veteran with a thorough and contemporaneous medical examination. Littke v. Derwinski, 1 Vet.App. 90, 92 (1990). In view of the foregoing, the case is REMANDED for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of all health care providers who have treated him for his psychiatric disability in the recent past and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of any treatment records identified by the veteran. The VA Medical Center in Tuskegee, Alabama, should also be contacted and asked to provide complete clinical records pertaining to treatment of the veteran at that facility since 1991. 2. Thereafter, the RO should schedule the veteran for a comprehensive VA psychiatric examination. This study is to be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations (1985). A medical history with notation of all time lost from work due to PTSD should be reported. All indicated tests, to include appropriate psychological studies with applicable subscales, must be conducted. The claims file must be made available to and reviewed by the examiner prior to the requested study. The examiner must assign a Global Assessment of Functioning (GAF) score, and explain what the assigned score represents. The complete rationale for any opinion expressed must be provided. 3. Thereafter, the RO should readjudicate the claim with consideration of all applicable legal criteria, including 38 C.F.R. § 3.321 (b)(1) (1994). A supplemental statement of the case should then be issued for all issues in appellate status and the veteran and his representative should be provided the applicable time frame in which to respond. The case should then be returned to the Board for further consideration, 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. CHARLES E. HOGEBOOM 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. 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. 38 C.F.R. § 20.1100(b) (1994).