BVA9501111 DOCKET NO. 93-05 897 ) 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 anxiety neuroses with tension headaches, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John J. Crowley, Associate Counsel REMAND The veteran performed active naval service from May 1963 to May 1970. This matter is currently before the Board of Veterans' Appeals (Board) on appeal from a June 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The veteran claims that his service-connected nervous disability is severe, with frequent migraine headaches, and difficulties obtaining and maintaining employment. In this regard, it is noted that, in March 1984, the RO denied the veteran service connection for migraine headaches. However, by rating decision in March 1985, the RO, finding clear and unmistakable error in the March 1984 rating decision, allowed service connection for tension headaches associated with the veteran's anxiety neurosis. Consequently, he is currently service connected only for tension headaches associated with his psychiatric disability, and not for any migraine headaches. It is unclear from the veteran's recent statements and the medical evidence now of record whether his current headaches are in fact the type associated with his service-connected nervous condition. In view of the foregoing, the veteran's claim appears to be well- grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). Further, the Board "'must review all issues which are reasonably raised from a liberal reading of the appellant's substantive appeal.'" EF v. Derwinski, 1 Vet.App. 324, 326 (1991) (quoting Myers v. Derwinski, 1 Vet.App. 127, 129 (1991)). At his December 1992 hearing at the RO, the veteran appears to have raised the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability. Further, the undersigned believes that additional information is required to determine the degree of industrial impairment resulting from the veteran's sole service-connected disability, an anxiety neurosis with tension headaches. The statutory duty to assist includes the duty to obtain thorough and contemporaneous VA examinations, including examinations by specialists when indicated, and the duty to obtain pertinent medical records. Caffrey v. Brown, 6 Vet.App. 377, 381 (1994); Hyder v. Derwinski, 1 Vet.App. 221 (1991); Green v. Derwinski, 1 Vet.App. 121 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). Since the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order to fulfill its statutory duty to assist the appellant to develop the facts pertinent to the claim. Ascherl v. Brown, 4 Vet.App. 371, 377 (1993). Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request him to clarify whether he is seeking a total disability rating based on unemployability due to service-connected disability. 2. The RO should request the veteran to identify all health care providers who may possess additional records pertinent to his claim. With any necessary authorization from the veteran, the RO should attempt to obtain copies of treatment records from all sources identified by the veteran which have not been previously secured. 3. The veteran should be requested to complete and return an up-to-date employment information statement. 4. The veteran should be afforded a VA social and industrial survey to assess his employment history and the effects his service-connected nervous disability has had on his employment status and day-to-day functioning. Interviews with the veteran's neighbors and disinterested acquaintances should be accomplished, if possible, concerning his daily activities. A written copy of the VA social worker's report should be associated with the claims folder. 5. The RO should arrange for a VA psychiatric examination of the veteran to determine all current manifestations of his service-connected neuropsychiatric disability. All indicated studies should be performed and the psychiatrist should comment on the degree of social and industrial impairment which the veteran experiences as a result of his service- connected psychiatric disability. If possible, the psychiatrist should attempt to distinguish between the tension headaches associated with the veteran's service-connected anxiety disorder and his nonservice-connected migraine headaches. If appropriate, a medical examination should be performed to make this determination. The psychiatric examiner should assign a numerical code under the Global Assessment of Functioning Scale (GAF) provided on pages 22 and 23 of the Quick Reference to the Diagnostic Criteria from DSM-III-R (Third Ed. Revised) (DSM- III-R). It is imperative that the physician include a definition of the numerical code assigned under DSM-III-R in order to comply with the requirements of Thurber v. Brown, 5 Vet.App. 119 (1993). The claims folder should be made available to the examiner for review prior to the examination of the veteran. 6. Thereafter, the RO should review the veteran's claim as stated on the title page of this decision. The rating decision should reflect that consideration was given to the provisions of 38 C.F.R. § 3.321(b)(1) (1993). If indicated, the RO should also adjudicate the issue of entitlement to a total disability rating based on individual unemployability. The veteran is advised that the claim for a total disability rating will not be before the Board unless the determination of the RO is unfavorable, and he files a timely notice of disagreement and completes all procedural steps necessary to appeal a claim to the Board in accordance with 38 U.S.C.A. § 7105 (West 1991). If the benefits sought on appeal are not granted to the veteran's satisfaction, he and his representative should be provided a supplemental statement of the case on all issues in appellate status, and they should be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to any ultimate outcome warranted. No action is required of the veteran until he is notified by the RO. 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).