BVA9504362 DOCKET NO. 93-10 141 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to a permanent and total disability evaluation for pension purposes. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran served on active duty from April 1969 to November 1970. This appeal arises from a February 1991, rating decision of the Department of Veterans Affairs (VA) Cleveland, Ohio, Regional Office (RO). On appeal the veteran has raised the issue of entitlement to service connection for a post traumatic stress disorder (PTSD). This issue was adjudicated by the RO in January 1993, however, no action has yet been taken on the notice of disagreement filed by the representative in an April 1993, VA Form 1-646. Accordingly, this matter is referred to the RO for appropriate action. REMAND In Murincsak v. Derwinski, 2 Vet.App. 363 (1992), the United States Court of Veterans Appeals (Court) held that medical records pertaining to an award of Social Security benefits are pertinent in a claim based on unemployability such as that presented here. Id at 370. As the veteran has reported his receipt of Social Security benefits, see the December 1992 VA psychiatric examination report, and no attempt has been made to secure the medical records upon which the Social Security Administration based their decision, further development is required. Further development is also required in light of the fact that ratings have yet to be assigned all of the veteran’s non-service connected disorders. In this respect, in Roberts v. Derwinski, 2 Vet.App. 387 (1992), the Court held that "[b]efore a permanent and total disability evaluation can be awarded, an evaluation must be performed under the Schedule for Rating Disabilities to determine the percentage impairment caused by each disability." Id. at 390 (emphasis added). In this case, however, the record does not reflect the assignment of any rating for the veteran’s arcus senilis, an eye disorder, which was found by a VA examiner in December 1990. The duty to assist the veteran in his claim also extends to securing pertinent medical records which he has identified. Littke v. Derwinski, 1 Vet.App. 90, 91 (1990). In this regard, the Board observes that the veteran reports ongoing inpatient and outpatient treatment at the VA Medical Center in Brecksville, Ohio. While some records have been added to the claims file it appears highly suspect that all of the records have been secured for consideration. Finally, the Board observes that the latest rating sheet confirming and continuing the February 1991 denial includes the assignment of a 10 percent rating for "PTSD (Not shown by evidence of record)" under the category "NSC (VE)." The Board reads the category assignment, that is, "NSC" to mean that the RO has decided that service connection for PTSD is not supported by the evidence of record. The basis for the assignment of a 10 percent rating, however, is unclear. If PTSD is not present, the assignment of a rating is error. If the listing of PTSD is based on a diagnosis based on an unverified inservice stressor that also is error in light of the Court’s decision in West v. Brown, 7 Vet.App. 70 (1994) (A diagnosis of PTSD may only be accepted for purposes of establishing service connection if there is evidence that the veteran engaged in combat, or in a case where the veteran did not engage in combat, if the claimed stressor has been verified. Compensation examinations which diagnose PTSD and rely on a claim of combat where the veteran did not engage in combat, and compensation examinations which diagnose PTSD and rely on an unverified stressor are inadequate for rating purposes. Id. at 77-8.) Of course it is possible that the RO in listing PTSD was stating that the diagnosis was based on a post- service stressor. If this latter conclusion is the case, however, the RO should note that fact on the rating sheet. Accordingly, to clarify this matter further development is warranted. Therefore, this case is REMANDED for the following action: 1. The RO should contact the Social Security Administration and request all of the medical records upon which they based their award of benefits to the veteran. 2. The RO should contact the VA Medical Center in Brecksville, Ohio, and request photocopies of all of the veteran’s outpatient records, as well as inpatient summaries, for the period since September 1990. 3. The veteran should be asked to provide more specific details about the stressful events he claims to have experienced in service. In this regard, the veteran should be asked to provide the precise dates and places of each claimed stressful event, as well as his unit assignment at the time of each claimed stressor. The veteran should further provide the units, names, and approximate dates of death of any comrades who were killed or wounded in action. The veteran is hereby informed that the United States Court of Veterans Appeals has held that requiring a claimant to provide this information to the VA does not represent an impossible or onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 4. Thereafter, the information provided by the appellant concerning the specific circumstances of the claimed stressors and a copy of the veteran's service records should be sent to the United States Army and Joint Services Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22150, for verification of the stressors claimed by the appellant. 5. Following the receipt of the ESG’s report, and the completion of any necessary development, the RO should prepare a report detailing the nature of any combat action, or stressful event, that has been verified by the ESG. If no combat or stressor has been verified, the RO should so state in their report. This report is then to be added to the claims folder. 6. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a psychiatrist who has not previously seen or treated the appellant. This examination is to be conducted in accordance with the VA Physician’s Guide for Disability Evaluation Examinations in order to determine the nature and extent of any current psychiatric disorder, including post-traumatic stress disorder, which may be present. All indicated studies, including post-traumatic stress disorder sub scales, are to be performed. The claims file must be provided to and reviewed by the examiner prior to conducting this examination. In determining whether the veteran has PTSD based on his military service the examiner is hereby notified that only the verified history detailed in the reports provided by the ESG and the RO may be relied upon. If the examiner believes that PTSD is the appropriate diagnosis the examiner must specifically identify which stressor detailed in the ESG’s or the RO’s report is responsible for that conclusion. Otherwise, the examiner must identify the post-service stressor which formed the basis for the diagnosis for pension purposes. All opinions expressed should be accompanied by a complete rationale. 7. Following the completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination report to verify that any diagnosis of PTSD due to military service is based on the verified history provided by the ESG and the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. Again, the Court has held that for purposes of determining entitlement to service connection a diagnosis of PTSD based on an examination which relies upon an unverified history is inadequate for rating purposes. 8. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to a permanent and total disability evaluation for pension purposes. This readjudication must include a review of all of the medical evidence of record to ensure that ratings are assigned for all disabilities presented in the record, and that ratings are not assigned for any disorder which is not presented. If the decision remains adverse to the veteran, he and his representative should be provided with an appropriate Supplemental Statement of the Case. The veteran and his representative should thereafter be provided an opportunity to respond thereto. The case should then be returned to the Board of Veterans' Appeals for further appellate consideration if otherwise in order. The Board intimates no opinion, legal or factual, as to the ultimate disposition of the veteran’s appeal. No action is required of the appellant until he receives further notice. DEREK R. BROWN 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).