Citation Nr: 0000460 Decision Date: 01/06/00 Archive Date: 01/11/00 DOCKET NO. 93-06 494 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUE Entitlement to service connection for post traumatic stress disorder (PTSD). WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michael F. Bradican, Associate Counsel INTRODUCTION The veteran served on active duty from October 1967 to October 1970. This case arises before the Board of Veterans' Appeals (Board) on appeal from a rating decision of February 1992, from the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA). This claim was before the Board in May 1995. It was remanded for further evidentiary development. All requested development has been accomplished. FINDINGS OF FACT 1. PTSD was diagnosed during a VA hospitalization in June and July 1993 by Dr. Ariel Cabrera. 2. In August 1996, Dr. Cabrera completed a detailed evaluation of the veteran's record and concluded there was not enough objective evidence to warrant a diagnosis of PTSD. 3. The report of the most recent VA examination, in March 1999, is negative for a diagnosis of PTSD. No other medical records show a diagnosis of PTSD. CONCLUSION OF LAW The veteran's claim for service connection for PTSD is not well grounded. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991 & Supp. 1998); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. A person who submits a claim for benefits under a law administered by VA shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial tribunal that the claim is well-grounded. VA shall assist such a claimant in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a). If he has not presented evidence of a well-grounded claim, his appeal must fail as to that claim, and there is no duty to assist him further in the development of his claim because such development would be futile. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). In order for a claim for service connection to be well- grounded, there must be competent medical evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that a layperson is not competent to establish medical causation. Layno v. Brown, 6 Vet. App. 465 (1994). A review of the record shows that the veteran first claimed service connection for nervousness in April 1971. VA examination in June 1971 showed a diagnosis of anxiety reaction. Service connection was denied in a rating decision of August 1971. He attempted to reopen his claim in April 1973. VA examination in March 1973 showed a diagnosis of chronic anxiety reaction. Service connection was again denied, by a rating decision of April 1973. In July 1973 he was hospitalized and diagnosed with schizophrenia. A rating decision of October 1973 denied service connection for schizophrenia. A Board decision of November 1976 upheld the prior denials, finding that, although the veteran had psychiatric symptoms which occurred in service, these were continuing manifestations of a pre- existing psychiatric abnormality. The Board also found that this disability did not undergo an increase in severity and was not related to his subsequently diagnosed schizophrenia. The veteran first claimed service connection for PTSD in January 1990. He stated, at his personal hearing in May 1992, that he served in combat in Vietnam with the 199th Light Infantry Brigade as a radio relay operator. He reported that he was involved in a vehicle accident and that he witnessed the deaths of two friends who were killed near him. A review of the medical evidence of record shows that the veteran was undergoing frequent psychiatric treatments and evaluations since his initial diagnosis of schizophrenia in 1973. The report of a board of two psychiatrists, who examined the veteran in October 1991, showed no sign of PTSD. The diagnosis was schizophrenia with depression. No private or VA health records, contained within the claims folder, indicate a diagnosis of PTSD until June and July 1993. At that time the veteran was hospitalized due to aggressive and destructive behavior at home. A diagnosis of PTSD, chronic, was entered by Dr. Ariel Cabrera. In May 1995 this claim was remanded to the RO, as the June/July 1993 hospital summary had not been reviewed by the RO and there was no waiver of RO consideration. The May 1995 Board decision requested that the attending physician review the record and set out the basis for the diagnosis of PTSD. In August 1996, Dr. Cabrera provided an addendum report for this purpose. He stated that after a detailed examination of the veteran's record, there was not enough objective evidence to warrant a diagnosis of PTSD. The report of a VA examination, conducted in March 1999, is likewise negative for a diagnosis of PTSD. The veteran contends that he has PTSD. He specifically asserts that he engaged in combat in Vietnam and that he has symptomatology related to that service. However, the evidence of record, including the report of the most recent VA examination, and Dr. Cabrera's addendum regarding the June/July 1993 hospitalization, does not include a diagnosis of PTSD. The veteran, himself, is not competent to provide a medical diagnosis. Layno, supra. Absent a competent diagnosis of PTSD and a medical opinion relating any current psychiatric disorder to service, the claim of service connection for PTSD is not well-grounded and must be denied. See Caluza, supra. ORDER Entitlement to service connection for PTSD is denied. M. S. SIEGEL Acting Member, Board of Veterans' Appeals