Citation Nr: 0007711 Decision Date: 03/22/00 Archive Date: 03/28/00 DOCKET NO. 98-12 090 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The veteran served on active duty from December 1951 to December 1954. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. FINDING OF FACT The claim for service connection for PTSD is plausible. CONCLUSION OF LAW The claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION A PTSD claim is well grounded if there is medical evidence of a current disability; lay evidence (presumed to be credible for these purposes) of an in-service stressor, which in a PTSD case is the equivalent of in-service incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD. Gaines v. West, 11 Vet. App. 353, 357 (1998). Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1999). The Board notes the aforenoted criteria for a well grounded claim have been satisfied. The record contains diagnoses of PTSD with stressors noted as related to the veteran's military service in Korea. These diagnoses were made by VA and private examiners. The veteran's statements concerning exposure to stressors are presumed credible. Therefore, the veteran's claim for service connection for PTSD is well grounded with in the meaning of 38 U.S.C.A. § 5107(a). That is, the Board finds that this claim is plausible. For reasons set forth below, the Board finds that further development in this matter is required. ORDER The veteran's claim for service connection for PTSD is well grounded, and his appeal with respect to this issue is granted to that extent only. REMAND As discussed above, the veteran has submitted a well grounded claim for service connection for PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (as amended by 64 Fed. Reg. 32,807-32808 (1999)) (effective March 7, 1997) (implementing the decision in Cohen v. Brown, 10 Vet. App. 128 (1997)). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat veterans). When a veteran submits a well grounded claim, VA has a duty to assist the veteran in developing facts pertinent to his claim. 38 U.S.C.A. § 5107(a); Epps, 126 F.3d at 1469. In PTSD claims, this duty includes assisting in the verification of the veteran's claimed in-service stressors. In this regard, the Board emphasizes that the evidence required to establish the in-service occurrence of a stressor varies depending on the RO's determination as to the veteran's status as a combat veteran. The Board notes that the veteran has supplied written statements describing traumatic events experienced in service. He has stated that he was in two fights with guerrillas and that at that time friends were wounded and killed. In a statement received by the RO in June 1998, the veteran reported that from July to November 1952, he was stationed on Wachum Reservoir at Ammunition Depot, and he reported on his activities there. Among other things, he stated that during that time, he was near the frontlines and that enemy patrols flew by every night, and if they saw lights would throw mortars. He stated that he witnessed a fuel dump being blown up nearby, and that he once saw a Korean soldier bleeding from his chest. He also reported that guerrillas once attacked a nearby MP station and were headed toward the ammunition dump. He stated that he led some men to the MP station to protect the ammunition dump. He reported that he fired on the enemy, that 9 MPs were killed and that he discovered the bodies of two men that he had lead. Both had been killed--one having been shot in the head and the other shot in the back or side. The duty to assist also includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69, 76 (1995). After the RO has completed its development as to the claimed in-service stressors, the RO should afford the veteran a VA psychiatric examination. Accordingly, the case is REMANDED to the RO for the following action: 1. The RO should contact the appropriate office at the National Personnel Records Center (NPRC) and request copies of the veteran's his service personnel records. 2. The RO should review all pertinent evidence, including the veteran's service records, and written statements, for evidence as to claimed in-service stressors. The RO should ask the veteran to clarify names, ranks, dates, locations, and other pertinent information required for verification of those stressors that he has reported and that are noted above. The RO should advise the veteran that this information is vitally necessary to obtain supportive evidence of the stressful events and that he must be as specific as possible because without such details an adequate search for verifying information cannot be conducted. In addition, the veteran should be informed of alternative methods for supporting his claim, such as letters, diaries and statements from service comrades concerning the events he has described in service. 3. The RO should then prepare a summary of all the claimed stressors. This summary and a copy of the veteran's separation documents and all associated service documents should be sent to the U.S. Armed Services Center for Research of Unit Records (USASCRUR), 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197. The USASCRUR should be provided with a copy of any information obtained above, and should be requested to provide any additional information from all available sources that might corroborate the veteran's alleged stressors. 4. Following the receipt of a response from the USASCRUR, the RO must prepare a report detailing the nature of any stressor it determined is established by the record. If no stressor has been verified, the RO should so state in its report. This report is then to be added to the claims folder. 5. After completing the above actions, the veteran should be afforded a VA psychiatric examination to determine the diagnosis of any and all psychiatric disorders which may be present. All indicated studies, tests and evaluations deemed necessary should be performed, to include psychological testing and PTSD sub scales. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 (1996), copies of all pertinent records in the veteran's claims file or, in the alternative, the claims file, must be made available to the examiner for review. Specifically, the RO must provide the examiner the summary of any stressors described above, and the examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in the current psychiatric symptoms. The examiner is asked to determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If a PTSD diagnosis is deemed appropriate, the examiner must offer an opinion as to whether the PTSD symptomatology is related to one or more of the in-service stressors found to be established by the RO. The report of examination should include the complete rationale for all opinions expressed. 6. After completing any necessary development in addition to that specified above, the RO should adjudicate the issue of entitlement to service connection for PTSD in light of relevant law, regulations, and court decisions. If the determination remains unfavorable to the veteran, the RO should furnish the veteran and his representative a supplemental statement of the case and provide an opportunity to respond. Thereafter, the case should be returned to the Board for final appellate review, if in order. The Board does not intimate any opinion as to the ultimate outcome of the veteran's claim. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the veteran until he is notified. F. JUDGE FLOWERS Member, Board of Veterans' Appeals