BVA9504419 DOCKET NO. 93-09 978 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for the cause of the veteran's death. 2. Entitlement to an evaluation in excess of 50 percent for atopic dermatitis for accrued benefits purposes. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, Harry Shubin, M.D., and [redacted] ATTORNEY FOR THE BOARD Paul J. Somelofske, Associate Counsel INTRODUCTION The veteran served on active duty from February 1945 to February 1946. The appellant, who is the veteran's widow, is represented in this appeal by Disabled American Veterans. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 1991 rating decision of the Department of Veterans Affairs (VA), Philadelphia, Pennsylvania, Regional Office (RO), that denied service connection for the cause of the veteran's death, and a subsequent June 1991 rating decision that denied an evaluation in excess of 50 percent for atopic dermatitis for accrued benefits purposes. In April 1993, the appellant, Harry Shubin, M.D., and [redacted], testified at a hearing before a Member of the Board sitting in Philadelphia, Pennsylvania. REMAND The veteran died on March [redacted] 1991, at the age of 71. The Certificate of Death shows that the immediate cause of death was acute cardiac arrest, due to or as a consequence of coronary insufficiency, arteriosclerotic, due to or as a consequence of generalized severe atopic dermatitis, due to or as a consequence of shock/stress syndrome, secondary to dermatitis. At the time of his death, the veteran was service connected for atopic dermatitis, evaluated as 50 percent disabling, and residuals of a fracture of the distal phalanx, second left finger, evaluated as zero percent disabling. In September 1992, the RO requested that a board of physicians, consisting of at least one cardiologist and one dermatologist, review the entire record to determine whether the veteran's death was attributable to the severity of his service-connected atopic dermatitis. In October 1992, however, an opinion from only one physician was received, indicating that it was unlikely that the veteran's skin condition contributed to his death. At the April 1993 Board hearing, the veteran's private physician, Harry Shubin, M.D., testified that the shock and stress associated with veteran's service-connected atopic dermatitis hastened the development and was a contributing factor in the veteran's arteriosclerotic coronary insufficiency and acute cardiac arrest which caused his death. Dr. Shubin also testified that he had treated the veteran for atopic dermatitis and had prescribed prednisone, given over periods of seven to ten days. Dr. Shubin opined that the veteran's use of prednisone was a factor in the development of diabetes mellitus. Dr. Shubin indicated that he was pretty certain that he was not the only physician who had prescribed prednisone for the veteran; he noted an October 1989 letter from Cassandra Venable, M.D., a dermatologist, who said the veteran was referred to the Dermatology Clinic of the VA Hospital in Philadelphia, Pennsylvania, and that when she saw him, he had been treated with tapering doses of oral prednisone. Any records reflecting medications prescribed for the veteran are necessary to assess any relationship between the use of prednisone and the development of additional disability. The evidence of record indicates that the veteran had been referred to Dr. Alexander Erhlich for tests and treatment. Treatment records from Dr. Ehrlich have not been associated with the claims folder. Dr. Shubin also testified that the veteran had been hospitalized in Center City Hospital on two occasions in 1979 for cardiovascular problems and that he had been seen by two cardiologists, Dr. Hyman and Dr. Helwig. It was stated that Dr. Hyman had been at Germantown Hospital in Philadelphia, but is now at a VA hospital in Maryland; and that Dr. Helwig is still with Germantown Hospital. Dr. Hyman's and Dr. Helwig's records have not been obtained. It was also indicated that the veteran was seen at Temple University Hospital in Philadelphia. The VA has a duty to assist the appellant in the development of facts pertinent to her claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994). This duty includes assisting the appellant in securing clinical and treatment records when such records exist, but are not on file. Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App. 90 (1990). Under the circumstances of this case, it is believed that further development is necessary prior to the final disposition of the issues on appeal. This case, therefore, is REMANDED to the RO for the following actions: 1. The RO should afford the appellant the opportunity to submit or identify any other evidence pertinent to her claims for service connection for cause of the veteran's death and an evaluation in excess of 50 percent for atopic dermatitis for accrued benefits purposes. Any evidence identified should be obtained by the RO, and all evidence secured should be associated with the claims folder. Also, the appellant should specifically be asked to identify medical care providers who treated or evaluated the veteran for diabetes mellitus and arteriosclerotic heart disease. Records showing when these diseases were first manifested are particularly important. With the appellant's consent, copies of the veteran's records should be obtained. 2. With the appellant's consent, the RO should contact Dr. Harry Shubin at 1829 Pine Street, Philadelphia, Pennsylvania, 19013, and attempt to obtain copies of all medical records not now on file, including those of medications prescribed for and administered to the veteran in conjunction with his service-connected atopic dermatitis. It is essential to obtain legible copies of records showing the dates and dosages of all prescribed prednisone and legible records showing the initial findings of diabetes and arteriosclerotic cardiovascular disease. All records obtained should be associated with the claims folder. 3. With the appellant's consent, the RO should contact Dr. Cassandra Venable at Dermatology Associates, 2 West Gates Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, 19104-4283, or through the VA Hospital in Philadelphia, Pennsylvania, and attempt to obtain copies of all medical records pertaining to the veteran, to include any records pertaining to medications prescribed and administered in conjunction with his service-connected atopic dermatitis. All records secured should be associated with the claims folder. 4. The RO should also contact the VA Hospital in Philadelphia, Pennsylvania, and request the veteran's complete, original medical records, including any records of medication prescribed. All records secured should be associated with the claims folder. 5. With the appellant's consent, the RO should contact Dr. Alexander Ehrlich at Dermatology and Dermatologic Surgery, 1900 Rittenhouse Square, Philadelphia, Pennsylvania, 19103, and request copies of the veteran's medical records, to include any records pertaining to medications prescribed and administered to the veteran in conjunction with his service-connected atopic dermatitis. All records secured should be associated with the claims folder. 6. With the appellant's consent, the RO should contact Center City Hospital in Philadelphia, Pennsylvania, and request copies of the complete records of the veteran's hospitalizations in October 1979 and December 1979, to include reports of laboratory studies and information regarding medications. All records secured should be associated with the claims folder. 7. With the appellant's consent and assistance, the RO should contact Dr. Hyman and Dr. Helwig, and request copies of the veteran's medical records. It is noted that Dr. Hyman was at Germantown Hospital in Philadelphia, Pennsylvania, but is now at a VA hospital in Maryland, and that Dr. Helwig is still with Germantown Hospital. All records secured should be associated with the claims folder. 8. With the appellant's consent, the RO should contact Temple University Hospital in Philadelphia, Pennsylvania, and request copies of the veteran's complete medical records. All records secured should be associated with the claims folder. 9. Following completion of the foregoing, the RO must ensure that all of the requested development has been conducted and completed in full to the extent possible. If any development is incomplete, appropriate corrective action is to be taken. 10. Thereafter, the RO should review the case. If deemed appropriate, further development should be undertaken, such as obtaining a medical opinion as to the relationship, if any, between the veteran's service-connected skin disorder and/or medication for the disorder and his death. If an opinion is obtained, Dr. Shubin's argument regarding the relationship between presdnisone and diabetes should be addressed and if such a relationship is found, there must be an opinion as to any relationship between diabetes and arteriosclerotic heart disease. Whether the skin disorder, itself, was a material factor in causing, contributing to or hastening the veteran's death also would have to be discussed. The claims folder and a separate copy of this remand should be provided to any physician rendering an opinion. The rationale for the opinion must be stated. After the above has been completed and the claims readjudicated, if either benefit on appeal remains denied, the appellant and her representative should be issued a supplemental statement of the case, which includes adequate reasons and bases for the RO's decision. Thereafter, they should be afforded an opportunity to respond. The case must then be returned to the Board for further appellate consideration. The appellant and her representative need take no further action until notified by the RO. By this remand, we intimate no opinion, either factual or legal, as to the ultimate decision warranted. 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).