Citation NR: 9700334 Decision Date: 01/08/97 Archive Date: 02/03/97 DOCKET NO. 95-01 427 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to an increased rating for service-connected post-traumatic stress disorder, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The veteran and a clinical psychologist ATTORNEY FOR THE BOARD Susanne Blume, Associate Counsel REMAND The veteran had recognized service from February 1981 to May 1984 and from January 1985 to November 1992. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 1994 determination of the San Diego, California Regional Office (RO) of the Department of Veterans Affairs (VA), which granted service connection for PTSD with a 10 percent disability rating. In a subsequent determination the veteran was granted a 50 percent disability rating. This case is presently before the Board because when a claimant has filed a notice of disagreement with an RO decision assigning a particular disability rating, subsequent RO decisions awarding a higher rating but less than the maximum available benefit do not abrogate the pending appeal. AB v. Brown, 6 Vet.App. 35 (1993). The veteran has received two VA PTSD examinations, in December 1993 and in February 1996. Since the last VA examination the VA Schedule of Ratings for Mental Disorders, has been amended and redesignated as 38 C.F.R. § 4.130, effective November 7, 1996. 61 Fed. Reg. 52695-52702 (October 8, 1996 ). Under the new regulation, the evaluation criteria for mental disorders have substantially changed, focusing on the individual symptoms as manifested throughout the record, rather than on medical opinions characterizing overall social and industrial impairment as mild, definite, considerable, severe, or total. The United States Court of Veterans Appeals has held that a liberalizing change in a regulation during the pendency of a claim must be applied if it is more favorable to the claimant, and if the Secretary has not enjoined its retroactive application. Marcoux v. Brown, 9 Vet.App. 289 (1996) (vacated on reconsideration and reissued as No. 95-52 U.S. App. Dec. 19, 1996 ). Consequently, the Board finds that the veteran should be re- examined in accordance with the newly implemented diagnostic criteria to determine the current severity of the veteran’s PTSD. In addition, there is testimony from the veteran's doctor, as well has a letter from her therapist that the veteran has had a great deal of difficulty in maintaining employment. The veteran should have a social and industrial survey to determine her employability. Accordingly, in view of the foregoing, this matter is REMANDED to the RO for the following actions: 1. The RO should request that the veteran provide the complete dates of treatment, if any, as well as the names and addresses of all health care providers where she has received treatment since December 1993. After obtaining the necessary authorization from the veteran, the RO should contact the medical care providers identified and request copies of treatment records that are not already incorporated in the claims file. 2. The RO should schedule the veteran for a VA psychiatric examination, with someone who has not examined her previously, in order to determine the extent of the service-connected PTSD with consideration of the new criteria for evaluation of psychiatric disorders. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the psychiatrist) should be conducted in order to identify and describe the symptomatology attributable to PTSD. The report of examination should contain a detailed account of all manifestations of the disability found to be present. The examiner should express an opinion on the extent to which PTSD affects occupational and social functioning. A multi-axial assessment should be conducted, and a thorough discussion of Axis IV (psychosocial and environmental problems) and Axis V (Global Assessment of Functioning (GAF) score), with an explanation of the numeric code assigned, is to be included. The claims folder and a copy of this remand must be made available to the physician for review in conjunction with the examination. 3. The veteran should be afforded a VA social and industrial survey to assess the veteran's employment history and day- to-day functioning. A written copy of the report should be inserted into the claims folder. 4. After the development requested above has been completed to the extent possible, the RO should again review the record. The RO should evaluate the veteran’s claim under a broad interpretation of the applicable regulations, consistent with 38 C.F.R. §§ 4.3 and 4.7 (1995), and with consideration of the mental disorders rating criteria in effect prior to and as of November 7, 1996. If the benefits sought on appeal remain denied the veteran and her representative should be furnished a supplemental statement of the case, containing all applicable laws and regulations not previously included. They should be given a reasonable opportunity to respond. They should also be informed of the need to file a notice of disagreement and/or substantive appeal where applicable in order to allow for Board consideration of any additional issues. Thereafter, the case should be returned to the Board for further appellate consideration, if warranted. No action is required of the veteran until she receives further notice. By this remand, the Board intimates no opinion as to the ultimate outcome of this case. V. L. JORDAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (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) (1995). - 2 -