Citation Nr: 0001118 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 98-15 433 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD T. Stephen Eckerman, Associate Counsel INTRODUCTION The appellant had active duty service from August 1964 to July 1966. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a May 1998 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied the appellant's claim of entitlement to service connection for post-traumatic stress disorder (PTSD). FINDING OF FACT The claims file includes a medical diagnosis of PTSD related to service. CONCLUSION OF LAW The veteran's claim of entitlement to service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION The veteran asserts that he has PTSD as a result of witnessing stressors during his service in Vietnam. A claim for service connection for PTSD is well grounded where the veteran submits medical evidence of a current disability; lay evidence (presumed to be credible for these purposes) of an inservice stressor, which in a PTSD case is the equivalent of inservice incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD disability. Gaines v. West, 11 Vet. App. 353 (1998). As noted in Gaines, the veteran's assertions of an inservice stressor are presumed to be true for well-grounded purposes. Further, the claims file contains a letter from William Reid, M.D., dated in July 1998, and a report from a Veterans Center, dated in February 1998, which show that the veteran has been diagnosed with PTSD. Dr. Reid's letter indicates that the veteran's PTSD is related to his service in Vietnam. The Board finds that this evidence is sufficient to constitute medical evidence of a diagnosis of PTSD, and a nexus to active duty, such that the veteran's claim for PTSD is well grounded within the meaning of 38 U.S.C.A. § 5107(a). ORDER The veteran's claim of entitlement to service connection for PTSD is well-grounded. To this extent, the appeal is granted subject to the following remand provisions. REMAND Having submitted a well-grounded claim for PTSD, a remand is required in order to assist the veteran in developing the facts pertinent to his claim. 38 U.S.C.A. § 5107(a). An actual award of service connection for PTSD (as opposed to well-grounding such a claim) requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), 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); see also Gaines v. West, 11 Vet. App. 353 (1998). The veteran argues that he has PTSD as a result of his service in Vietnam. Specifically, in a letter received in February 1998, he claimed that he has PTSD as a result of the following as stressors: 1) witnessing an enemy attack on his base, to include a mortar attack, at an otherwise unspecified date and location; 2) witnessing a Viet Cong terrorist attack in Saigon in which a grenade was thrown into a truck, resulting in one or more casualties; and 3) the deaths of two men, identified as "Gilmore Christy" and "Ed Christie." The Board initially notes that the veteran's personnel record (DA Form 20) is not currently associated with the claims file. On remand, this record should be obtained. In addition, as the veteran has set forth significant details of a stressor involving the deaths of two men (i.e., their names), as listed above, a remand is required to attempt to verify this stressor. M21-1, Part IV, paragraph 11.38(f). In this regard, however, the Board notes that a review of the letter from the veteran, received in February 1998, shows that the veteran did not indicate whether he actually witnessed these deaths, and, if so, the date, location and circumstances involved. Furthermore, he failed to supply dates, specific locations and units involved for the stressors involving an attack on his base, and the grenade attack on a truck. Therefore, at present, additional information is required. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that it is not an impossible or onerous task for appellants who claim entitlement to service connection for PTSD to supply the names, dates and places of events claimed to support a PTSD stressor); see also VA Adjudication Procedure Manual (M21-1), Part IV, paragraph 11.38(f)(2). The Board has therefore determined that the RO should attempt to obtain further details from the veteran, followed by an attempt at verification. See M21-1, Part IV, paragraph 11.38(f)(2). The veteran's personnel record (DA Form 214) lists his military occupation specialty as medical specialist. His awards include the Vietnam Service Medal. He has received no decorations evincing combat service, see 38 C.F.R. § 3.304(f) (1998), and there is nothing currently in the claims file which establishes participation in combat. Service medical records indicate that the veteran was a member of 616th Medical Company (Clearance). Absent confirmatory evidence of participation in combat, the record must contain service records or other corroborative evidence which substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressors. See West (Carlton) v. Brown , 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993); Cohen v. Brown, 10 Vet. App. 138 - 150 (1997). As the veteran has set forth significant details of one of his stressors, as listed above, a remand is required to attempt to verify these stressors. Finally, the Board notes that although the claims file contains a PTSD diagnosis from Dr. Reid, other documents from Dr. Reid, apparently created in conjunction with a request for a leave of absence from the post office, show that Dr. Reid indicated that the veteran was being treated for depression, frustration and agitation, and that he was disabled as of October of November of 1997. In addition, the claims file contains treatment reports from Richard D. Hefley, L.S.W., dated in March 1998, which show numerous complaints relating to the veteran's job at the post office, and which do not contain any mention of the veteran's Vietnam service. The diagnosis was major depression. Therefore, at present, the evidence is conflicting as to whether the veteran has PTSD. On remand, if the RO determines that any stressors are verified, an examination should be scheduled to determine whether the veteran has PTSD, and, if so, whether such PTSD is related to a verified inservice stressor. Accordingly, this case is hereby REMANDED for the following actions: 1. The RO should obtain the veteran's service personnel record (DA Form 20). 2. The veteran should be requested to provide additional information to facilitate a further search of the circumstances surrounding the stressors involving an attack on his base, a grenade attack on a truck, and the deaths of as "Gilmore Christy" and "Ed Christie," including the dates and locations of these incidents, the units and circumstances involved, and any other helpful identifying information. 3. Following the development requested in the first two paragraphs of this remand, or after the development requested in the first paragraph has been carried out, and after allowing a reasonable period of time to pass without a response pursuant to the second paragraph of this remand, the RO should formally determine whether the veteran engaged in combat with the enemy. If the RO determines that the veteran did not engage in combat with the enemy, then it should review the claims file and prepare a detailed list of all specifics reported by the veteran regarding the claimed stressors (date, names of individuals, veteran's unit, locations, etc.). This information should be furnished to the U.S. Armed Service Center for Research of Unit Records (USASCRUR), 7798 Cissna Road, Springfield, Virginia 22150-3197 with a request that that unit attempt to verify the veteran's stressors. Any additional action deemed necessary by the RO to verify the claimed stressors should also be accomplished. 4. The RO should then prepare a report detailing the nature of any claimed stressor(s) which it has determined is verified by the record. 5. If, and only if, the RO determines that one or more stressors have been verified, or that veteran has participated in combat, and 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, but should include psychological testing including PTSD sub scales. The RO must provide the examiner with 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 inservice stressor has resulted in the current psychiatric symptoms. The examiner should also determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should comment upon the link between the current symptomatology and one or more of the inservice stressors found to be established by the RO. The report of examination should include the complete rationale for all opinions expressed. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 (1999), 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. 6. After undertaking any additional development deemed appropriate, the RO should review the expanded record and adjudicate the issue of service connection for PTSD, to include a formal determination as to whether the veteran was engaged in combat. If the RO's decision is adverse to the veteran, then he and his representative should be furnished an appropriate Supplemental Statement of the Case and be afforded an opportunity to respond. The case should then be returned to the Board for further appellate review. The purpose of this remand is to obtain additional development, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The veteran and his representative are free to submit any additional evidence or argument in connection with this appeal. MILO H. HAWLEY Acting Member, Board of Veterans' Appeals