Service Connection Denied 12/02"

VADenialDec02

Justification or Humiliation

Department of Veterans Affairs
08/12/2002
CSS RA11761750

James Raab
xxx forest avenue
xxx Harbor NJ

Dear Mr. Raab

Service records show that on DA form 3082-R dated 08-25-71 the veteran signed the document indicating, that he underwent a separation medical examination more than 3 working days prior to his departure from his place of separation and to the best of his knowledge there has been no change in his medical condition. Service records do not show that the veteran fell from a watchtower in Vietnam.

Treatment summary from VAMC-Lyons dated 03-26-02 received 03-29-02. The veteran gives information about his history in Vietnam, and what happened to him. He reports that he fell from a watchtower in Vietnam. He remembers waking up somewhere, in a place that had indoor plumbing, and surmises that it was in a military hospital. He stated that he had become fearful and disoriented and was hiding in a bathroom crying, when people came to assist him. The veteran reports that his claim had been denied in the past, because of inability to recall his traumatic experiences and the dates upon which they occurred. The VA examiner at VAMC Lyons states based on the veteran's history, it appears that this veteran is unable to report these experiences because he suffered a head injury while in the war zone.

On the V A. exam dated 05-28-02, the veteran indicates he was shot at when he was going in a truck in Vietnam, by the enemy. The veteran states he saw dead people. At one point while in service, he states he fell out of a watchtower when he was in DA Nang and hurt his head. He states while he was in the DMZ (Not) he felt he was in danger for his life.

The V A. examination dated 05-28-02 the veteran gives a history of a head injury in Vietnam. The veteran indicates he was treated primarily for the head injury in Vietnam, than he was released. Later on, he does not exactly recall when he started to get seizures initially they were called generalized tonic clonic and then it was changed to partial type seizures. According to the veteran, his last seizure was about a few months ago, The V A. examiner stated the records show that initially the veteran was started on Phenobarbital with good results then his seizures got worse and are being treated with a new medication for seizures called Trileptal 1200mg twice a day. The veteran denies any recent seizure activities. The veteran indicates he had an outside CAT scan and EEG, and was given the diagnosis of temporal lobe seizures.

V A medical center treatment records reveal treatment at mental health clinic for PTSD. These records also include a report of hospitalization for PTSD at VA Medical Center Lyons between February 1997 and April 1997. V A neurology examination diagnosed temporal lobe seizures (complex partial seizures predominantly, most likely etiology is post traumatic seizure disorder)

The VA examiner indicates the veteran did have a history, of alcoholism and drug addiction, but currently the veteran denies any alcohol and drug abuse. The veteran indicates he has a history of post traumatic stress disorder and has a history migraine and tension type headaches. The veteran is currently on Imitrex for headaches. His other medications include Robaxin, Vioxx, and Risperdal. He also takes Trileptal for seizures. Diagnosis: Temporal lobe seizures (complex partial seizures predominantly, most likely etiology is post traumatic stress disorder).

The V A. psychotherapist Dr. Goldstein has seen you for bi-weekly individual psychotherapy sessions since August 2000. According to Dr. Goldstein you present with classic symptoms of PTSD with intrusive memories of Vietnam. She also states you reported falling from a watchtower in Vietnam.

Treatment records from the V A. New Jersey Health care system dated 12-26-2000 indicates the veteran had a serious accidental head injury in 12-2000; a heavy railroad tie weighing almost 100 lbs fell over his head. Fortunately, he did not suffer any skull fracture, but the scalp wound required several stitches.

In his May 11, 2001, letter Dr. Mueller stated as follows" Mr. James Raab (RA 11761750) has been treated by me for Temporal Lobe Epilepsy (TLE) which dates back to brain injuries suffered in the Vietnam war”. The doctor goes on to state that you "had been mistakenly treated for Post-Traumatic Stress Disorder over the past 30 years" until he saw you in 1998. At the conclusion of his letter, Dr. Mueller states "this does not deny the presence of Post Traumatic Stress Disorder which is also in evidence".

In his most recent letter (April 5, 2002) Dr. Mueller states you suffered a head injury in 1970. He states you were "serving with the Special Forces (Not the ASA) in Da Nang, South Vietnam and fell from a tower". Treatment report from Peter Muller indicates the veteran is being treated for temporal lobe epilepsy, which dates back to the brain injuries suffered in the Vietnam War, as per veteran. The doctor indicates he initially saw the veteran in 1998. The veteran clearly had smell, taste, touch, visual, and auditory hallucinations, blanking out periods, and virtually all symptoms of TLE. Treatment report from Peter Mueller indicates the vet is being treated for Temporal lobe Epilepsy.

Report from Medical Center at Princeton states a brain scan found partial epilepsy with impairment of consciousness. The report also referred to a history of head injury in Vietnam.

Your service records reveal you served in Vietnam from November 1969 to November 1970. Your principal duty is given as "Elect Recorder. Repairman" There is no evidence of any decoration which would indicate you were in combat. Nor is there any evidence, other than you served in Vietnam, that you were ever exposed to a stressful situation(s) which would result in PTSD. There is also no evidence that, while in service, you fell from a tower or anywhere else in Vietnam and injured your head.

Service connection may be granted for a disability with documentation that it began in military service or was caused by some event or experience in service. Service connection for posttraumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred in Vietnam, and a link, established by medical evidence, between current Symptomatology and the claimed in-service stressor.
If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. Additionally, confirmed prisoner of war status is considered conclusive evidence of a stressor.

Rating decision dated 06-21-95 denied the veteran service connection for post traumatic stress disorder. The rating decision indicated there was no evidence on record to corroborate the veteran’s history of stressful events.
The veteran reopened his claim on 09-25-97 for post traumatic stress disorder and was told that new and material evidence is needed. The veteran indicated he remembers the names of some people he served with. He did not provide those names, nor did he list the stressful experience required to identify an in-service stressor.

1. Service connection for PTSD is denied since the evidence reviewed does not establish that the stressful experience occurred in Vietnam nor was caused by service.

2. Service connection for epilepsy is denied since the evidence reviewed does not establish that this condition occurred in Vietnam, nor was caused by service.

Sincerely Yours,
Kathleen Sullivan

Thank You, Jim Raab http://www.jimraab.blogspot.com/