BVA9500211 DOCKET NO. 93-03 296 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, rated 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. P. Hanson, Counsel INTRODUCTION The veteran served on active duty from April 1967 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of June 1990 by the St. Petersburg, Florida, Regional Office (hereinafter RO), denying the veteran entitlement to an evaluation in excess of the then currently assigned 10 percent rating for post-traumatic stress disorder (PTSD). During the pendency of the appeal, the RO, in a rating decision of April 1992, increased his evaluation for PTSD to 30 percent. The veteran continues to assert that he is entitled to an evaluation in excess of that assigned. REMAND The undersigned notes that the veteran's hearing, scheduled for January 1992, was cancelled at the request of his representative by memorandum in January 1992. An April 1992 hearing was rescheduled, but his representative indicated that the veteran could not attend it because he would be out of the state until October 1992, at which point he would like to be heard by a hearing officer on the issue of an increased rating for PTSD. Subsequently, in April 1992 letter from the RO, the veteran was asked to notify them in the future, if he still wished a hearing rescheduled. As this matter remains unresolved, it is the subject of further development below. The threshold question is whether the veteran has met his burden of submitting evidence sufficient to justify a belief that his claim is well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). The Board finds that the veteran's evidentiary assertion of increased symptoms that a lay party is competent to report, viewed in conjunction with the medical evidence in file, is sufficient to establish a plausible claim and one that is well-grounded. Proscelle v. Derwinski, 2 Vet.App. 629 (1992). A preliminary review of the record and arguments advanced by the veteran indicate that the fundamental question herein is whether the veteran's psychiatric symptoms are productive of an evaluation in excess of a 30 percent evaluation, currently in effect. In this respect, we note that the veteran has been extensively hospitalized since about 1989, that he was last examined by the Department of Veterans Affairs (VA) in February 1992, and that such examination did not include an opinion as to the degree to which his PTSD symptoms were productive of social and industrial inadaptability. In this regard, during the course of recent medical examinations and psychiatric hospitalizations, the veteran's psychiatric diagnoses have included various nonservice-connected mental disabilities, such as schizophrenia, major depression, and bipolar disorder, as well as his service- connected PTSD. In addition, in a statement of February 1993, the representative asserted that the veteran had been in receipt of disability benefits from the Social Security Administration (SSA) since 1987. The VA has a duty to assist the veteran in the development of facts pertinent to his claim, as mandated by 38 U.S.C.A. § 5107(a). In addition, in Schafrath v. Derwinski, the United States Court of Veterans Appeals (the Court) held that, in a claim for increased disability compensation benefits, a complete history is required. Lastly, in view of the fact that the representative recently stated that the veteran is in receipt of benefits from the SSA, development in reference to supporting medical records from that agency must also be initiated. See Murincsak v. Derwinski, 2 Vet.App. 363 (1991). To ensure that the VA has met its duty to assist the veteran in developing the facts pertinent to the claim, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and ascertain from him whether he still desires a hearing on appeal. If he answers in the affirmative then a hearing should be scheduled. 2. The RO should obtain from the SSA copies of the records pertinent to the veteran's claim for Social Security disability benefits, as well as the supporting medical reports relied upon concerning that claim. See 38 U.S.C.A. § 5106 (West 1991); 38 C.F.R.§ 3.201(a) (1993). 3. The RO should contact the veteran and obtain the names and addresses of all medical care providers who have treated him for his neuropsychiatric disability since February 1992. After securing the necessary authorizations for release of information, the RO should endeavor to obtain these records, including any records of VA hospitalization for treatment of his PTSD since 1992, not already of record. 4. The veteran should be afforded a VA social and industrial survey to assess his employment history and day-to-day functioning. The VA social worker should be asked to interview the veteran, if possible, as well as any disinterested acquaintances, in order to assess the degree of the veteran's industrial impairment due solely to the service- connected PTSD. A written copy of the report should be associated with the claims folder. 5. Thereafter, the RO should schedule the veteran for a psychiatric examination by two psychiatrists who have not previously seen him. The claims folder should also be made available to the examiners for their review prior to the examination. If coexisting psychiatric disorders, in addition to PTSD, are found to be present, the examiners should reconcile the diagnoses and/or specify which symptoms are associated with each of the disorder(s) identified. If certain symptomatology cannot be dissociated from one disorder or another, it should be so specified. The examiners should describe all of the symptoms specifically attributable to PTSD and indicate the degree to which the veteran's social and industrial capacity is affected thereby. The examiners should include a numerical code under the Global Assessment of Functioning Scale (GAF) provided in the American Psychiatric Association's Diagnostic and Statistical Manual on Mental Disorders, (3rd ed. Revised (1987) DSM-III-R). The examiners must include a definition of the numerical GAF code associated under DSM-III-R in order to comply with the requirements of Thurber v. Brown, 5 Vet.App. 119 (1993). 6. At the conclusion of the above, the RO should review the examination reports and ensure that they are in conformity with the requests stated in this REMAND. To the extent that they are not, any deficient examination report should be returned to the examining psychiatrist for corrective action. Upon completion of the developments so far described, the RO should review the veteran's claim on appeal. Should the veteran be dissatisfied with any aspect of the RO's decision, both he and his representative should be issued a supplemental statement of the case, and given a reasonable period of time in which to respond. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. No action is required on the part of the veteran or his representative until further notice is received. By this action, the Board intimates no opinion, legal or factual, as to the ultimate disposition warranted. J.F. GOUGH 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) (1993).