BVA9506196 DOCKET NO. 93-27 231 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to a permanent and total disability rating for pension purposes. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel REMAND The veteran had active service from August 1954 to July 1958. This appeal arises from a July 1993 rating decision of the Indianapolis, Indiana, Regional Office (RO). The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. A June 1993 VA neurology examination report recommended that the veteran receive an MRI and an EMG to evaluate his neck, that a computed tomography scan be conducted to evaluate the low back, and that the veteran be examined by a neurologist or a neurosurgeon. A June 1993 VA orthopedic examination report recommended that diagnostic testing be completed to rule out carpal tunnel syndrome. A May 1993 VA psychiatric examination report recommended that a collateral interview with a significant other and a psychological evaluation would be of assistance in evaluating the veteran. In view of the foregoing recommendations, following the gathering of all medical records, the veteran should be afforded a VA general medical examination and VA orthopedic, neurology, and psychiatric examinations. VA has a duty to assist the veteran in the development of facts pertaining to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). The veteran has been receiving ongoing treatment at the Marion VA medical center; all recent treatment records should be obtained and associated with the claims file. Several cases have been decided by the Court which impact significantly upon claims for non-service connected pension benefits. In Roberts v. Derwinski, 2 Vet.App. 387 (1992), the Court held that each disability in a pension case must be assigned a percentage rating, that the RO should discuss the diagnostic codes used in denying a claim, and that a rating decision may not be based on an examination which was conducted before all relevant evidence was gathered. In Brown v. Derwinski, 2 Vet.App. 444 (1992), the Court held that a pension claim must be considered under both the average person, 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. § 4.15 (1993), and the unemployability standards, 38 C.F.R. §§ 3.321, 4.17 (1994). Complete development in conformity with the points addressed above in Roberts and Brown should be accomplished. Moreover, VA has a duty to acknowledge and consider all regulations which are potentially applicable through 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, the Board finds that further assistance is required. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and obtain the names and addresses of all health care providers where he has received treatment in recent years. Thereafter, the RO should obtain legible copies of all records which have not already been obtained to include those from the Marion VA medical center from February 1993 to the present. All records should be associated with the claims folder. 2. Following completion of the above development, the veteran should be afforded a VA general medical examination and VA orthopedic, neurology and psychiatric examinations to determine the nature and extent of all disabilities present. All indicated tests, to include an MRI and EMG of the neck and left upper extremity, a tomography scan of the lower back, complete psychological testing and an interview with the veteran's significant other, should be accomplished. It is imperative that the physicians review the claims folder prior to the examinations. All disabilities should be evaluated in relation to their history, with emphasis upon the limitation of social and industrial activity, including any time lost from employment, imposed by the disabling conditions in light of the whole recorded history. Each examiner should render an opinion as to what effect the disabilities found would have on the veteran's ability to work or perform work-related activities, and state whether the veteran's disabling conditions are susceptible to improvement through appropriate treatment. The factors upon which the medical opinions are based must be set forth. 3. When the above developments have been completed, the case should again be reviewed by the RO and a rating action prepared which lists all of the veteran's disabilities and the percentage evaluation assigned each disability. If the decision remains adverse to the veteran, he and his representative should be furnished with a supplemental statement of the case which includes a recitation of the percentage rating for each diagnosed disability; the appropriate diagnostic codes and a discussion of their applicability to the veteran's disabilities; and a discussion of the application of the two standards (average person and unemployability under 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. §§ 3.321, 4.15, and 4.17 (1993)) by which a permanent and total disability rating for pension purposes may be assigned. The parties should then be afforded the applicable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. CHARLES E. HOGEBOOM 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).