BVA9508016 DOCKET NO. 93-10 302 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for residuals of an injury to the right leg and right knee. 2. Entitlement to service connection for a psychiatric disorder, to include post-traumatic stress disorder. 3. Entitlement to service connection for residuals of a neck and back injury. 4. Entitlement to service connection for a bilateral foot disorder. 5. Entitlement to service connection for a heart disability. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, his mother and Mr. [redacted]. ATTORNEY FOR THE BOARD K. J. Alibrando, Associate Counsel INTRODUCTION The veteran served on active duty from December 1960 to December 1963. This appeal arises from a March 1992 rating decision in which the RO determined that new and material evidence had been submitted to reopen a claim for service connection for residuals of an injury to the right leg and right knee and, on the basis of all of the evidence of record, determined that service connection was not warranted. In addition, the RO denied the veteran's claim for service connection for a bilateral foot disorder and a heart disability. This appeal also arises from an October 1992 rating decision in which the RO denied the veteran's claims for service connection for residuals of a neck and back injury and a psychiatric disorder, to include post-traumatic stress disorder. A hearing was held on July 2, 1993 in Washington, D.C. before C.W. Symanski, who is the member of the Board rendering the determination in this claim and was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b)(West 1991). REMAND The veteran contends he was aboard a personnel carrier which sank while crossing the Rhine River in October 1962. He asserts that he injured his neck and back as a result of that incident. He also contends that exposure to icy water for approximately one hour contributed to his health problems, including his right knee disability. He further asserts that the currently diagnosed psychiatric disorder is a result of that incident. In addition, the veteran seeks service connection for a heart disability and a bilateral foot disability which he contends were incurred during active service. He asserts that forced marches contributed to those conditions. The veteran also asserts that he injured his right leg and right knee in the fall of 1963. In July 1993, the veteran testified that he was aboard an armored personnel carrier in October 1962 which sank while crossing the Rhine River, 80 miles south of Frankfurt, Germany. He reported being assigned to Headquarters, the 32nd Infantry, 3rd Armored Division, in Freiberg, Germany. He has sated that an investigation was conducted into the accident. He asserts that he incurred an injury to his back as a result of that incident and also attributes his psychiatric disorder to that incident. The VA examination of October 1992 includes a diagnosis of post-traumatic stress disorder, noting the stressor as reported by the veteran. The RO, in denying the veteran's claim, noted that the reported stressor had not been verified and concluded that the overall evidence was insufficient to support a grant of service connection. However, it would appear that there is sufficient information regarding the armored personnel carrier incident to attempt to verify that stressor. The RO should contact the U.S. Army and Joint Services Environmental Support Group and request verification of the contended stressor. In January 1992, the veteran submitted a copy of a decision of the Social Security Administration which granted Social Security disability benefits to the veteran. Copies of the medical records on which that determination was based have not been obtained. The United States Court of Veterans Appeals (Court) in Masors v. Derwinski, 2 Vet.App. 181 (1992) has held that the duty to assist a veteran under 38 U.S.C.A. § 5107(a)(West 1991) includes an obligation to obtain the records of a Social Security Administration adjudication awarding disability benefits. In July 1993, the veteran testified that he first received treatment at the VA Medical Center in Salisbury, N.C., for a broken ankle and for right knee and back disabilities in the early 1970. The earliest VA outpatient records included in the claims folder are dated in February 1984. In addition, the veteran testified that he received treatment for his right knee and back from Dr. Charles Lockhart in the 1970's. In January 1992, the veteran submitted copies of records showing treatment by Dr. Lockhart dated from November 1989 to April 1991. The RO has not requested copies of earlier records from Dr. Lockhart and it is unclear from the record whether earlier records are available. The veteran also indicated that he Dr. Bumgardner, an anesthesiologist, currently prescribed medications for his psychiatric disorder. Those records have not been obtained. The VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994). The U.S. Court of Veterans Appeals has held that the duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining treatment records to which the veteran has referred. Littke v. Derwinski, 1 Vet.App. 90 (1990). The RO should obtain the treatment records referred to above. A review of the veteran's service medical records shows that in July 1962 he reported foot pain on the heel and the diagnoses included third degree pes planus. In addition, the veteran reported heart pains at night. In October 1962 the veteran was seen for back pain. Records dated from April through July 1963 show treatment for a right knee disability. The October 1963 separation examination includes a diagnosis of asymptomatic bilateral second degree pes planus. Fulfillment of the statutory duty to assist includes conducting a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet.App. 121 (1991). The Court has held that the VA is obligated to give the veteran a medical examination to include a medical opinion as to whether his current disabilities are in any way related to those he may have experienced in service. Moore v. Derwinski, 1 Vet.App. 401 (1991). The RO should afford the veteran additional VA examinations. Finally, the VA has a duty to acknowledge and consider all regulations which are potentially applicable to the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Under the circumstances of this case, we find that additional development is required. Accordingly, the case is REMANDED to the RO for the following: 1. The RO should contact the veteran and request him to furnish the full name and address of Dr. Charles Lockhart and Dr. Bumgardner from whom he has received treatment. Consent forms for the release to the VA of those private medical records should be obtained from the veteran. Thereafter, the RO should obtain legible copies of all treatment records of Dr. Charles Lockhart dated from 1970 to 1989 pertaining to the veteran's knee and back disability. The records of Dr. Bumgardner concerning all treatment of the veteran's psychiatric disorder should be obtain. Thereafter, all records should be associated with the claims folder. 2. The RO should obtain copies of all VA outpatient records concerning treatment of the veteran's disabilities from 1970 to the present time. All records obtained should be associated with the claims folder. 3. The RO should obtain copies from the Social Security Administration of the determination which awarded benefits to the appellant and the medical records used as a basis to award those benefits. 4. The RO should contact the U.S. Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150 and request verification of the alleged stressor as reported by the veteran at the hearing in July 1993. A photocopy of the portions of the transcript (Pp. 14, 15, 16, 17, 23, 24, 33, 34) containing the veteran's description of the incident and unit of assignment at the time of the incident should be forwarded to the Support Group along with the request for verification of the stressor. The response form the Support Group must be associated with the claims folder. 5. After the above mentioned records have been obtained, the veteran should be afforded special VA orthopedic, cardiovascular and psychiatric examination to determine the nature and extent of his disabilities. Such tests as the examiner deems necessary should be performed. The claims folder should be made available to the examiner prior to the examination so that they may review pertinent aspects of the veteran's medical history. The orthopedic and cardiovascular examiners should each render an opinion as to the relationship between any currently diagnosed disabilities and any inservice complaints as reflected in the veteran's service medical records. 6. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examinations do not include all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. When the above developments have been completed, the case should be reviewed by the RO. If the decision remains adverse to the appellant, he and his representative should be afforded a supplemental statement of the case and afforded a reasonable opportunity to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration. C.W. SYMANSKI 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).