BVA9502554 DOCKET NO. 92-12 016 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for a chronic back disability, to include chronic residuals of a back injury. REPRESENTATION Appellant represented by: Sandra E. Booth, Attorney ATTORNEY FOR THE BOARD L. Jennifer Lane, Associate Counsel INTRODUCTION The veteran had active service from April 1969 to April 1971. The appeal arises from a January 1991 rating decision in which the Regional Office (RO) denied service connection for a psychiatric disorder and a back disability. In January 1993, the Board of Veterans' Appeals (Board) issued a decision denying service connection for an acquired psychiatric disorder and a back disability, to include chronic residuals of a back injury. The veteran subsequently filed an appeal with the Court of Veterans Appeals (Court). In [citation redacted], the Court vacated the Board's January 1993 decision and remanded the case to the Board for another decision consistent with the Court's decision. REMAND In a VA Form 21-4138 (Statement In Support Of Claim) received in August 1991, the veteran related that four to six months prior to his separation from service in 1970 he was treated at a private hospital in Germany for seeing and hearing things that were not there. In another VA Form 21-4138 dated in September 1991, the veteran related that he was treated at the German hospital for a nervous breakdown in 1971. However, there is no evidence that the RO attempted to obtain records from any hospital in Germany or that the RO attempted to obtain any additional information from the veteran regarding treatment at such a facility. The veteran also reported having received treatment for psychiatric complaints at a VA facility in April 1990 in a VA Form 21-526 (Veteran's Application For Compensation Or Pension) received in April 1990. However, the claims file includes no VA outpatient treatment records. Additionally, in July 1990, a VA examiner diagnosed chronic schizophrenia, undifferentiated type. The physician also reported the veteran had experienced multiple episodes of psychosis over the years starting when he was in service. However, according to the examination report, the veteran was not able to provide a thorough and detailed psychiatric history. Under the circumstances, the Board finds that another psychiatric examination is warranted. The Board also finds that another examination of the back is warranted in order to reconcile the various diagnoses offered by private doctors and a VA physician. Those diagnoses include anomalous lumbosacral segment with some degenerative facet changes, dorsal and lumbosacral ligamentous sprain and myositis, and degenerative joint disease of the lumbosacral spine. To ensure that VA has met its duty to assist the veteran in developing the facts pertinent to his claims, the case is REMANDED to the RO for the following development: 1. The RO should ask the veteran to provide the name and location of the private hospital in Germany at which he received treatment during service and the approximate dates of treatment. The RO should then attempt to secure any records regarding such treatment from that facility. If the RO is not able to secure such records, it is requested that the RO explain why that is the case. 2. The RO should also request copies of all VA treatment records pertaining to treatment of the veteran from April 1990 to the present. 3. The RO should then schedule the veteran for a VA psychiatric examination which should be performed in accordance with the VA Physician's Guide for Disability Evaluation Examinations and should include all necessary tests and studies. Additionally, the examiner must be allowed the opportunity to review the veteran's claims file prior to the examination. The purpose of this examination is to ascertain the nature of any current acquired psychiatric disorder. After reviewing the veteran's claims file, including all service medical records, any records received as a result of the above action, records of prior psychiatric treatment and the July 1990 VA examination report, the examining physician should provide an opinion as to the date of onset of any acquired psychiatric disorder and what relationship, if any, exists between any current acquired psychiatric disorder and the veteran's service. It is requested the examiner provide the reasons for the decision. 4. The RO should also schedule the veteran for a VA orthopedic examination which should be performed in accordance with the VA Physician's Guide for Disability Evaluation Examinations and should include all necessary tests and studies. The examiner must be allowed the opportunity to review the veteran's claims file prior to the examination. The purpose of this examination is to ascertain the nature and severity of any current back disorder. 5. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action unless otherwise notified. LAWRENCE M. SULLIVAN 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).