BVA9500955 DOCKET NO. 93-09 110 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Auer, Counsel REMAND The veteran served on active duty from June 1957 to May 1961 and from January 1962 to June 1969. This appeal arises from a November 1991 rating decision of the Department of Veterans Affairs (VA), Houston, Texas, Regional Office (RO). In that decision, service connection for PTSD was granted and a 30 percent evaluation was assigned. The veteran's claim was appealed and received at the Board of Veterans' Appeals (Board) in April 1993. Since that time, additional evidence has been received. This additional evidence was received without a waiver of the veteran's right to have that evidence initially considered by the RO. Any pertinent evidence submitted by the veteran or representative which is accepted by the Board must be referred to the RO for review and preparation of a supplemental statement of the case, unless this procedural right is waived by the appellant. See 38 C.F.R. § 20.1304(c) (1993). The veteran has not waived his procedural rights and, in view of other necessary developments described below, this claim must be returned to the RO for consideration of the evidence submitted directly to the Board. The veteran has alleged that the symptoms associated with service- connected PTSD are so severe that he is prevented from obtaining or keeping a job. In a letter dated in December 1993, E. B. Gripon, M.D., P.A., he stated that he had treated the veteran over a twelve month period and that the veteran is totally disabled because his PTSD is so severe. Although the veteran was given a psychiatric examinations by the VA in June 1991 and in September 1992, further evaluation would be helpful, especially on the specific issues of whether the symptoms of PTSD are totally incapacitating, or whether there is demonstrable inability to maintain employment. Additionally, if other records of treatment are available, they should be obtained and considered as part of the current claim. The Board finds that further development is warranted before a final decision in this appeal. Accordingly, the claim is REMANDED for the following actions: 1. The RO should contact the veteran and ask him to furnish the names and addresses of all medical personnel and facilities from whom he has received treatment for the disability at issue since April 1991. After obtaining the necessary authorization from the veteran, the RO should obtain available records from the named sources. 2. The RO should obtain any available treatment records from the VA hospitals or medical centers where the veteran has received treatment since September 1992. Care should be taken by the RO so that duplicate records are not placed in the claims file. 3. The veteran should undergo a VA social and industrial survey to ascertain the manner and extent to which the service-connected disorder impairs his ability to work and relate to other people. Comprehensive information should be obtained and reported in accordance with Paragraph 1.14 of the VA Physician's Guide for Disability Evaluation Examinations (1985). Complete information concerning the veteran's work history and the reasons for his discontinuation of work should be obtained. 4. The veteran should then be scheduled for a VA psychiatric examination to determine the nature and extent of all current psychiatric pathology. The examination should be conducted in accordance with the requirements of the VA Physician's Guide for Disability Evaluation Examinations, specifically Chapter 14. The examination report should be typewritten. All necessary psychological testing should be conducted. The examiner should express an opinion as to the veteran's level of functioning as measured by the Global Assessment of Functioning Scale (GAF Scale) as stated in the Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised l987) (DSM-III- R), and the degree of impairment of the veteran to perform substantially gainful employment due to PTSD. It is essential that the claims folder be provided to the examiner for review in connection with the examination. 5. After the above actions have been completed, the case should again be reviewed by the RO, to include the adjudication of the issue of entitlement to a total rating under 38 C.F.R. § 4.16(c) (1993), if in order, as well as all applicable legal criteria. The RO should then review the veteran's claim in light of all the evidence and applicable legal criteria. If his claim remains denied, the veteran and his representative should be provided with a supplemental statement of the case that includes any additional pertinent law and regulations and a full discussion of the evidence in his case. The appropriate response time should be allowed. The case should then be returned to the Board, if in order, after compliance with all regulatory appellate procedures. No action is required of the veteran until he is so informed. The Board intimates no opinion as to the ultimate decision warranted in this case pending completion of the requested development. 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 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) (1993).