BVA9402067
DOCKET NO.  93-20 990     )       DATE
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THE ISSUE

Entitlement to service connection for post-traumatic stress disorder
(PTSD).

REPRESENTATION

Appellant represented by: Disabled American Veterans

WITNESSES AT HEARING ON APPEAL

Appellant, his spouse, Doris Frey, and Jessie M. Gregorskiwicz, Ph.D.

ATTORNEY FOR THE BOARD

Christine E. Puffer, Associate Counsel

INTRODUCTION

The veteran had active service from December 1967 to June 1970.

Entitlement to service connection for PTSD was denied by a rating
decision of the Department of Veterans Affairs (VA) San Diego,
California, Regional Office (RO) in July 1986.  The veteran's notice
of disagreement was received in April 1987.  The RO issued a
statement of the case in July 1987, which was remailed in
March 1988 because the veteran had changed his address.  The
veteran's substantive appeal was received in August 1987.  In
February 1989, the RO in Reno, Nevada, confirmed and continued the
denial of service connection for PTSD and issued a supplemental
statement of the case that same month.  Subsequent rating decisions
by the RO in San Diego, in November 1990, May and June 1991, and
October 1992 confirmed and continued the denial of service connection
for PTSD and another supplemental statement of the case was issued in
November 1992.  The veteran filed a VA Form 9 in December 1992.

The issue of entitlement to service connection for PTSD was certified
to the Board in February 1992 and a rating decision on appeal was
issued in March 1993.  A hearing was held in San Diego, California,
in September 1993, before Charles E. Hogeboom, who is a member of the
Board section rendering the final 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).  The claims folder was received
and docketed at the Board in September 1993.

REMAND

The veteran's tour of duty included one year's service in the
Republic of Vietnam.  At the hearing in September 1993 the veteran,
his wife, an aunt, and a treating psychologist all provided testimony
in support of the veteran's claim.  The veteran's treating
psychologist indicated that he had diagnosed the veteran as having
PTSD.  The veteran testified as to the circumstances of his Vietnam
service, including how he was affected by the death of a man named
"Mike" whom he had met during the Tet Offensive.  Further stressors
were cited including daily artillery fire and mortar attacks, and
being shot at while on a convoy.  He served as a cook in Vietnam and
was not directly involved in combat or wounded.  He was reportedly
assigned to the 25th Infantry Division located in Da Nang, Cu Chi,
and Delta A.  The veteran stated that another friend from his unit,
"Secora", had been killed during their term of service and indicated
the death had been difficult for him.  We note that the veteran's
service personnel records have not been associated with the claims
file.

Based on the statements offered by the witnesses at the hearing, the
Board determines that the veteran has submitted a well-grounded claim
within the meaning of 38 U.S.C.A. § 5107(a) (West 1991).  Once a
veteran has submitted a well-grounded claim, the VA has a duty to
assist him in the development of facts pertinent to his claim.
Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990).  This duty is
heightened where, as here with service records, the putative
corroborative records are in the control of a governmental agency.
Gobber v. Derwinski, 2 Vet.App. 470, 472 (1992).  The development of
evidence by the RO regarding verification of a veteran's claimed
stressor is governed by evidentiary requirements contained in the
Department of Veterans Affairs Adjudication Procedure Manual, M21-1,
Part VI.  It is necessary to develop the evidence when records
available to the RO do not provide objective or supportive evidence
of the claimed stressor.  Paragraph 7.46f (2), Part VI, M21-1.
Therefore, the veteran's service records should be obtained and
associated with the claims file.  The Environmental Services Group
should then be requested to attempt to verify the veteran's stressors
as stated in order to assist the veteran in the substantiation of his
claim.

Dr. Gregorskiwicz testified that he had begun providing the veteran
with psychological treatment approximately two years previously on
the request of Dr. Leon, a psychiatrist who had worked with the
veteran.  No records of his treatment and psychological evaluation of
the veteran have been obtained, nor have similar records been
obtained from Dr. Leon.  The VA's statutory duty to assist includes
the duty to obtain pertinent medical records, especially those
specifically brought to the attention of the VA.  Littke v.
Derwinski, 1 Vet.App. 90, 92-93 (1990).  The Board determines that
Dr. Gregorskiwicz's and Dr. Leon's records would be helpful in
evaluating the veteran's claim, particularly in view of their
treatment relationship with respect to the veteran and the former
physician's diagnosis of PTSD.

The veteran indicated at the hearing that he was receiving continuing
treatment at the San Diego VA Medical Center (VAMC).  As the most
recent record on file from that facility is dated in February 1991,
current records should be obtained to assist in the equitable
adjudication, and complete evaluation, of this claim.  In this
regard, we note that there has been testimony from the veteran
suggesting that he received treatment from a VA facility in 1972
shortly after separating from service.  The earliest VA medical
record on file is a psychiatric evaluation performed in October 1974.
A search should be conducted in order to determine whether earlier
treatment records may be available.  Review of the claims file
reveals indications that the veteran was hospitalized for depression
at the La Jolla VAMC in 1972 and had been treated at the San Diego
VAMC for neuropsychiatric reasons in 1973 and 1974.  The RO should
attempt to determine if these records are indeed available and, if
so, associate the same with the claims folder.

We note that the veteran's representative has requested that a VA
examination be performed.  The Board is persuaded that a current
psychiatric examination, following the development otherwise
requested, would be helpful.

Therefore, in order to give the appellant every consideration with
respect to the present appeal, it is our opinion that further
development of the case is desirable.  Accordingly, this case is
REMANDED for the following actions:

1.  The RO should contact the National Personnel
Records Center and request the veteran's service
personnel records and associate the same with
the claims folder.  After this has been
completed, the RO should contact the U.S. Army
and Joint Services Environmental Support Group
(ESG) for confirmation of the incidents as
alleged by the veteran, in accordance with
Paragraph 7.46f(2)(c), Part VI, of M21-1.  If
necessary, the veteran should be asked to
specify the details of all events he claims as
stressors.

2.  After obtaining any necessary authorization,
the RO should obtain from
Dr. Jessie Gregorskiwicz copies of all records
of any psychiatric treatment and/or evaluation
accorded the veteran.

3.  After obtaining any necessary authorization,
the RO should obtain from
Dr. Leon copies of all records of any
psychiatric treatment and/or evaluation accorded
the veteran since 1979.

4.  The RO should contact the San Diego VAMC and
request copies of all records of psychiatric
treatment and/or evaluation of the veteran from
February 1991 to the present.  The RO should
also request copies of any such treatment
accorded the veteran from 1972 to 1974.

5.  Once the above development has been
completed, the veteran should be afforded a VA
psychiatric examination to determine the nature
and extent of any current psychiatric disorder.
Any psychiatric tests or evaluations deemed
necessary by the examiner should be performed.
The examiner is specifically requested to offer
an opinion as to whether the veteran has post-
traumatic stress disorder.  Since this diagnosis
requires consideration of information regarding
a stressor, the claims folder or photocopies of
pertinent information must be made available to
the examiner.

Upon completion of the requested development, the RO should again
review the case.  After consideration of all evidence obtained, if
the benefit sought is not granted, the appellant and his
representative should be furnished with a supplemental statement of
the case which includes all pertinent laws and regulations and a
thorough discussion of the reasons for the decision reached.  The
appellant and his representative should be afforded the applicable
period to respond before the record is returned to the Board for
further review.

The purpose of this REMAND is to obtain additional development.  The
Board does not intimate any opinion as to the merits of the case,
either favorable or unfavorable, at this time.  No action is required
of the appellant unless he is notified.

BOARD OF VETERANS' APPEALS
WASHINGTON, D.C.  20420

                  *
          WARREN W. RICE, JR.      (MEMBER TEMPORARILY ABSENT)

          CHARLES E. HOGEBOOM

*38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of Veterans'
Appeals Section, upon direction of the Chairman of the Board, to
proceed with the transaction of business without awaiting assignment
of an additional member to the Section when the Section is composed
of fewer than three Members due to absence of a Member, vacancy on
the Board or inability of the Member assigned to the Section to serve
on the panel.  The Chairman has directed that the Section proceed
with the transaction of business, including the issuance of
decisions, without awaiting the assignment of a third Member.

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).