BVA9504755 DOCKET NO. 91-12 312 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a non-skin disorder of the feet, either as a residual of injury or Agent Orange exposure. 2. Entitlement to service connection on a direct and secondary basis for hypertension. 3. Entitlement to service connection for headaches as a disorder separate and apart from service-connected post-traumatic stress disorder (PTSD) with an anxiety reaction associated with headaches. 4. Entitlement to an increased rating for PTSD with an anxiety reaction associated with headaches, currently evaluated as 50 percent disabling. 5. Entitlement to a total rating based on individual unemployability, due to service-connected disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Brian J. Milmoe, Counsel REMAND The veteran served on active duty from August 1968 to September 1969. This case was most recently before the Board of Veterans' Appeals (the Board or BVA) in May 1991, at which time issues involving the veteran's entitlement to service connection for headaches and a disorder of the feet and an increased rating for an anxiety reaction with headaches were remanded to the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, for the completion of certain development actions. While the case was pending before the RO, various other issues were raised by the veteran, including entitlement to service connection for hypertension and PTSD, an increased rating for a skin disorder, and a total rating based on individual unemployability. By rating action of the RO in February 1994, the grant of service connection for an anxiety reaction with headaches was expanded to include PTSD, although the previously assigned 50 percent rating remained unchanged; aside from a grant of a temporary total rating for a period of hospitalization in 1993, all of the other benefits sought were denied. Upon return of the case to BVA, it is apparent that several additional actions are required, prior to the BVA's adjudication of the merits of the issues presented. Specifically, no action has to date been taken with respect to multiple requests for an additional hearing received by the RO in 1993 and 1994. As well, additional evidentiary development is needed to obtain medical records identified by the veteran and it is evident that the findings from the most recent VA psychiatric examination were more attuned to ascertaining whether PTSD was present, as opposed to the severity of the overall service-connected psychiatric disability. So that additional corrective actions may be undertaken, the case is again REMANDED to the RO for the completion of the following actions: 1. In light of hearing requests made in 1993 and 1994, the RO should contact the veteran in writing in order to determine if he continues to desire a hearing, and, if so, whether he wishes to appear before RO or BVA personnel. If a RO hearing is desired, such a proceeding should be scheduled and appropriate notice of the date and time of the hearing should then be forwarded to the veteran and his representative. If a BVA hearing is sought, arrangements therefor will be made upon return of the case from the RO. 2. The RO should obtain copies of all clinical records relating to treatment for hypertension, as well as psychiatric and foot disorders, at Metropolitan Hospital (1970-1972), Morrisanna Hospital (1969- 1970), and Fordham Hospital (April-August 1970), for which VA Forms 21-4142 were furnished to RO personnel in February 1994. Additionally, the RO should contact a former treating physician, J. R. Del Cueto, M.D., 2739 Felton Drive, No. 107, East Point, Georgia, in order to determine if the veteran was examined or treated subsequent to October 1990, and, if so, copies of all examination and treatment records compiled after October 1990 should be obtained and added to the claims folder (Note that a VA Form 21-4142 for Dr. Del Cueto was filed in September 1991). Copies of all treatment records compiled at the South Fulton Mental Health Center, 1636 Connally Drive, East Point, Georgia, since 1990 should be secured and associated with the other evidence of record. 3. Based on the veteran's noted involvement in Day Hospital treatment at the VA Medical Center in Decatur, Georgia, beginning in March 1994, records specifically relating to such treatment should be obtained and added to the claims folder. Also, copies of all treatment records, both inpatient and outpatient, compiled at the Decatur facility since 1992 should be secured for inclusion in the claims folder. 4. Through direct contact with the Social Security Administration, the RO should obtain all medical and administrative records compiled in connection with that agency's reported award of disability benefits to the veteran. Once obtained, those records should be made a part of the claims folder. 5. The veteran's VA vocational rehabilitation folder and any training sub- folder should be obtained and associated with the evidence already of record. 6. Any and all development deemed warranted, including a medical examination, should be undertaken regarding the veteran's claim for a foot disorder, as a residual of Agent Orange exposure. 7. Thereafter, the veteran should be afforded a VA psychiatric examination in order to determine the nature and severity of his service-connected PTSD with an anxiety reaction associated with headaches. Such examination should be conducted in accordance with Chapters 14 and 20 the VA's Physician's Guide for Disability Evaluation Examinations. Any and all indicated tests, including psychological studies, should be performed. Subsequent to the examiner's review of the entirety of the claims folder and a detailed mental status examination of the veteran, the examiner should identify the various manifestations of the veteran's service- connected psychiatric disorder and offer a professional opinion as to the severity of such disorder. Additionally, the examiner should be asked to describe the Global Assessment of Functioning Scale and the score assignable for the veteran's service- connected psychiatric disorder, with reasons therefor. The entirety of the claims folder should be made available to the examiner for use in the study of this case. Thereafter, the record should be reviewed in its entirety by the RO and the claims readjudicated. The merits of any claim should not be addressed unless it is determined that such claim is well- grounded under 38 U.S.C.A. § 5107(a) (West 1991). If the action taken remains adverse to the veteran in any way, he and his representative should be provided a supplemental statement of the case. They should then be afforded a reasonable period of time in which to respond. The case should then be returned to the Board for further appellate consideration. ALBERT D. TUTERA 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).