Citation Nr: 9905485 Decision Date: 02/26/99 Archive Date: 03/03/99 DOCKET NO. 97-17 380 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. Pomeranz, Associate Counsel INTRODUCTION The appellant served on active duty from January 1965 to January 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 1996 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Los Angeles, California. FINDINGS OF FACT 1. The appellant's clinical signs and manifestations of his service-connected PTSD are productive of severe social and industrial impairment; and of social industrial impairment with reduced reliability and productivity due to such symptoms as depression, sleep difficulties, anxiety, an exaggerated startle response, suicidal ideation, flashbacks, nightmares, and unprovoked irritability with periods of violence. 2. There is no competent medical evidence of record of a nexus, or link, between any current hearing loss and an incident of the appellant's military service. 3. There is no competent medical evidence of record of a nexus, or link, between the appellant's current tinnitus and an incident of the appellant's military service. CONCLUSIONS OF LAW 1. The criteria for a 70 percent evaluation for PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.102, 4.7, 4.132, Diagnostic Code 9411 (1998). 2. The appellant's claim for service connection for bilateral hearing loss is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998). 3. The appellant's claim for service connection for tinnitus is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Entitlement to an increased rating for PTSD, currently evaluated as 30 percent disabling. I. Factual Background An outpatient treatment record from the VA Hospital (VAH) in New York shows that in October 1967, the appellant was treated after complaining that he could no longer "control" himself. At that time, the appellant stated that he was suffering from inexplicable episodes of multi-directed rage, usually appearing after prolonged periods of social detachment. The appellant indicated that he also had marked feelings of depersonalization and sexual inadequacy. According to the appellant, his current illness developed shortly after his discharge from the military. The appellant noted that at present, he was a participant in the VA Day Hospital Program. The October 1967 outpatient treatment record from the New York VAH shows that at that time, the examining physician reported that the appellant was an excellent and faithful participant of the Day Hospital Program. The examiner noted that the appellant was not a problem for the program staff and he had not exhibited any bizarre behavioral patterns. Upon mental status evaluation, there was no overt psychotic appearance, but the degree of self alienation appeared indicative of a borderline adjustment. The appellant was diagnosed with chronic anxiety reaction with sexual deviation in schizoid personality. He was directed to continue the day treatment program. In September 1996, the appellant submitted a statement which included his occupational history since his discharge from the military. The statement reflects that from 1968 to 1995, the appellant held numerous jobs including working as an apartment doorman, bartender, lumberman, theater employee, hair stylist, and "prop" person." In addition, the appellant noted that he had been employed as an industrial film worker and that he earned $1,000 for one day of work. He further indicated that he had worked intermittently as a movie extra and a "day player." According to the appellant, his movie jobs averaged one day job every two years. In September 1996, the appellant underwent a VA psychiatric evaluation. At that time, he stated that his experience in Vietnam had been "emotionally devastating" for him. He indicated that he remembered witnessing his friends being killed and having to carry their dead bodies. According to the appellant, he lost several friends and colleagues in the war. The appellant reported that following his separation from the military, instead of being considered a patriot and a hero, he was called a "killer" by his old friends. He revealed that he started to drink heavily, and he experienced nightmares with Vietnam content. According to the appellant, his nightmares lasted a few years. In the appellant's VA psychiatric evaluation, the appellant stated that at present, he suffered from chronic boredom and he had no interest in his life or work. He indicated that he was unable to maintain friendships, especially with men, and that he had a startle reaction to sudden loud noises. According to the appellant, he also had almost daily flashbacks to his Vietnam experiences. The appellant reported that he had continued to abuse alcohol and that he had been sober only for the last year. He noted that he had an erratic work history and that he was fired on numerous occasions because of his alcohol abuse. The appellant indicated that recently, he had been hospitalized for one week because of suicidal thoughts, depressed mood, and apathy. He reported that he was currently taking Prozac. According to the appellant, his first marriage was from 1967 to 1976. The appellant stated that he had two children from that marriage and that his wife left him because she could no longer cope with his depression and alcohol abuse. He indicated that he remarried in 1978 and that he was still married to his second wife. According to the appellant, he had one child from his current marriage. In the appellant's September 1996 VA examination, the examining physician noted that the appellant had started to cross dress over the past year. The examiner indicated that for several years, the appellant wore lipstick or isolated woman's clothing. According to the examiner, over the past year, the appellant started to wear full outfits and he appeared in public dressed like a woman. Upon mental status evaluation, the examiner stated that the appellant was cooperative with good eye contact. Speech was normal with a normal rate and rhythm. Thought process was linear and goal directed. Mood was described as depressed, and the appellant's affect had a full range. The appellant denied any current suicidal thoughts. There was no evidence of psychosis, and cognitive functions were intact. Insight and judgment were fair to good. The appellant was diagnosed with the following: (1) PTSD, chronic, (2) history of alcohol dependence, and (3) recurrent major depressive episodes. In October 1996, the appellant underwent a second VA examination. At that time, the appellant took the Minnesota Multiphasic Personality Inventory in order to assess his PTSD. The examiner stated that upon a review of the appellant's test results, the validity scales suggested that a standard interpretation of the appellant's profile would not reflect an accurate picture of his psychological functioning. According to the examiner, since the appellant's profile was invalid, the determination of whether he had PTSD was going to be made by using other sources of information, including a clinical interview. In November 1996, the RO received private medical records from the Kaiser Permanente Hospital, from September to December 1995. The records show that in September 1995, the appellant was treated after he stated that he felt depressed and suicidal. At that time, the appellant indicated that he thought about suicide everyday. The appellant further noted that he had a history of alcohol abuse and that he was currently drinking. The assessment was that the appellant was actively thinking of suicide, actively drinking, and suffering from depression. The remaining records reflect treatment for unrelated disorders. In a December 1996 rating action, the RO granted service connection for PTSD. At that time, the RO assigned a 10 percent disabling rating for PTSD. Outpatient treatment records from the VAMC in Los Angeles show that on January 8, 1997, the appellant was hospitalized. At that time, the examining physician noted that the appellant had a long history of depression and alcohol abuse. The examiner stated that the appellant's wife had brought him to the hospital because she could no longer deal with his alcohol dependence and his irritable mood. She indicated that he had started to act violently towards her and that he had physically attacked her prior to his hospitalization. The examiner reported that upon admittance, the appellant was wearing women's clothes, and he had a very labile mood, crying at times and saying jokes and laughing at other times. The appellant revealed that his problem originated while he was in the military at which time he started to act as a homosexual, and he was the "source" of "sexual pleasure" for other homosexual soldiers. According to the appellant, since that time, he had felt inferior and he had suffered from depression. The appellant stated that after his discharge from the military, he married his current wife and they had a child. The appellant's wife indicated that the appellant was a "kind" man at home and that they loved each other, but she was suffering from his alcohol problem, his recent violent behavior, and his unemployment. She noted that the appellant had never held any permanent job since his return from Vietnam. According to the appellant's wife, the appellant started to wear women's clothing several years ago, and he was beginning to wear women's clothes in public. The appellant indicated that he had been on Prozac "on and off" and that he had less need for sleep. The appellant's wife stated that the appellant was "better" when he took his Prozac. According to the appellant, he also suffered from suicidal ideation, but he did not have any current plans. Upon mental status examination, the examiner noted that the appellant was oriented x3. The examiner stated that the appellant was talkative and he denied any homicidal ideation. According to the examiner, the appellant suffered from delusions of worthlessness and suicidal ideation. The appellant had a "flight of ideas," and his insight and judgment were impaired. The appellant's perception was intact. The appellant was diagnosed with the following: (Axis I) alcohol induced mood disorder versus borderline personality disorder, mixed episode with comorbid alcohol dependence, (Axis II) deferred, questionable borderline personality disorder, (Axis III) alcoholism, (Axis IV) unemployment, and (Axis V) a Global Assessment of Functioning (GAF) score of 20. The Los Angeles VAMC records reflect that while the appellant was hospitalized, he underwent therapy. According to the records, on January 10, 1997, the examiner noted that the appellant was feeling better and he was less depressed. The examiner further stated that according to the appellant, he was still hearing a voice calling his name and that friends from Vietnam called him. The appellant indicated that he developed suicidal thoughts when he started feeling "hopeless." According to the examiner, the appellant was preoccupied with cross dressing and "sex change." The examiner recommended that the appellant undergo treatment at the Sepulveda VAMC for his PTSD and alcohol abuse. The examiner also recommended that the appellant receive treatment from a transsexual support group. The outpatient treatment records from the Los Angeles VAMC reflect that during the appellant's hospitalization, the examiner noted that the appellant's sleep pattern was moderately disrupted with frequent early night awakenings and an inability to return to sleep or relax. According to the examiner, the appellant's mood was anxious and depressed, and he was preoccupied with his sexual identity. The appellant denied hearing any voices, and he also denied any suicidal or homicidal ideation. According to the records, on January 23, 1997, it was determined that the appellant was no longer exhibiting threatening behavior and he was subsequently released the next day. Upon his discharge, the appellant was directed to continue with his therapy. In May 1997, a hearing was conducted at the RO. At that time, the appellant testified that he received therapy for his PTSD twice a week from a psychiatrist at the Sepulveda VAH. (T.2). The appellant indicated that he last worked in 1992 and that he could no longer work because he was always in a state of panic, anxiety, and trauma. (Id.). He stated that when he was working, he would argue and fight with his co-workers. (T.2,3). The appellant noted that at present, he looked after his house, which included doing the dishes and shopping, while his wife worked. (T.3). According to the appellant, he experienced flashbacks of his Vietnam experiences everyday. (Id.). The appellant reported that during service, he was a mortar man and he was involved in 12 months of combat. (Id.). He revealed that his flashbacks included visions of his friends dying in front of him and friends with the backs of their heads off. (Id.). The appellant further noted that he had nightmares at least twice a week. (T.3,4). According to the appellant, he never slept the whole night and at times, he would wake up three times a night. (T.4). The appellant stated that he was depressed "most of the time," and that he was currently taking Prozac. (Id.). He indicated that the Prozac calmed him down. (Id.). According to the appellant, he was very suspicious of people. (T.9). He testified that he had been married to his current wife for 19 years and that his relationship with her was "strained" because he was very "moody." (T.4,5,7). The appellant reported that although he had never tried to kill himself, he had thought about it a lot. (T.5). According to the appellant, he had never thought of harming others. (Id.). The appellant revealed that he had three children and that he was in contact with his eldest daughter and son, but that he hardly ever talked to his younger daughter. (Id.). He further stated that he had a history of alcohol abuse, and he was currently attending Alcoholics Anonymous meetings. (Id.). In October 1997, the RO received outpatient treatment records from the Sepulveda VAMC, from March to April 1997. The records show that in March 1997, the appellant underwent a psychodiagnostic assessment. At that time, the examining physician stated that there were differing diagnoses which were applicable to the appellant. The examiner indicated that it was unclear as to whether the appellant was suffering from gender identity disorder, transvestic fetishism, or possibly some aspect of an anxiety disorder. Upon mental status evaluation, the appellant was oriented x4 . There were no indications of any type of thought disorder, and his thought process was linear and goal directed with no tangentiality, circumstantiality, or other pathology. The appellant's thought content was appropriate for the interview. The appellant demonstrated a full range of appropriate affect and, despite expressing some appropriate anxiety, he was euthymic. There was no indication of any suicidal or homicidal ideation, and there was no evidence of any delusional material. The examiner noted that the appellant was enrolled in a clinic for further evaluation. The Sepulveda VAMC outpatient treatment records reflect that in April 1997, the appellant complained that he was depressed and anxious. The appellant stated that he continued to have flashbacks and nightmares of his Vietnam experience. According to the appellant, he had poor sleep patterns and a loss of appetite. The appellant noted that on occasion, he heard voices of his friends from Vietnam. He reported that he continued to have problems with alcohol and gender identity. The appellant was diagnosed with the following: (Axis I) PTSD, major depressive disorder (MDD), history of alcohol abuse, (Axis IV) facing sexual identity issues, and (Axis V) GAF score of 55 to 60. In a January 1998 rating action, the RO increased the appellant's rating for his service-connected PTSD from 10 percent to 30 percent disabling. II. Analysis A claim for an increased rating is regarded as a new claim and is subject to the well-groundedness requirement. Proscelle v. Derwinski, 2 Vet. App. 629, 631 (1992). In order to present a well grounded claim for an increased rating of a service-connected disability, the appellant need only submit his or her competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation. Proscelle, 2 Vet. App. at 631, 632; see also Jones v. Brown, 7 Vet. App. 134 (1994). The appellant has stated that the symptoms of his service-connected PTSD have increased. The Board finds that the appellant's claim is well grounded within the meaning of 38 U.S.C.A. § 5107. Disability evaluations are administered under the VA Schedule for Rating Disabilities that is found in 38 C.F.R. Part 4 (1998) and are designed to compensate a veteran for the average impairment in earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1 and 4.2 (1998). It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102 (1998). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1998). The Board notes that the schedular criteria for evaluation of psychiatric disabilities were changed effective November 7, 1996. 61 Fed. Reg. 52695-52702 (Oct. 8, 1996). Where a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to an appellant applies unless Congress provided otherwise or permitted the Secretary to do otherwise and the Secretary does so. Marcoux v. Brown, 9 Vet. App. 289 (1996); Karnas v. Derwinski, 1 Vet. App. 308 (1991); see also VAOPGCPREC 11-97 (1997). Thus, the appellant's psychiatric disorder must be evaluated under both the old and the new rating criteria to determine which version is most favorable to him. As noted above, the veteran is currently evaluated as 30 percent disabled under 38 C.F.R. § 4.132 Diagnostic Code 9411. Diagnostic Code 9411 provides the rating criteria for PTSD. The rating criteria in effect for mental disorders prior to November 1996, are as follows: A 50 percent evaluation is for assignment where the ability to establish or maintain effective and wholesome relationships with people is considerably impaired and, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent evaluation is warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired, and there are psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain and retain employment. A 100 percent evaluation requires that attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community and there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. The individual must be demonstrably unable to obtain or retain employment. Effective November 7, 1996, the General Rating Formula for Mental Disorders is as follows: A 50 percent rating is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where the disorder is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Regarding the claim for an increased rating for PTSD, the Board has reviewed the pertinent evidence of record and determines that the appellant's disability picture for his service-connected PTSD, although currently evaluated as 30 percent disabling, more nearly approximates the criteria required for a 70 percent evaluation under both the old and new provisions of Diagnostic Code 9411. 38 C.F.R. § 4.7. In this regard, the Board notes that in the appellant's September 1996 VA psychiatric evaluation, the appellant indicated that at present, he had a startle reaction to sudden loud noises. He stated that he had almost daily flashbacks to his Vietnam experiences, and he was recently hospitalized because of suicidal thoughts, depressed mood, and apathy. According to the appellant, he was currently taking Prozac. The appellant was diagnosed with the following: (1) PTSD, chronic, (2) history of alcohol dependence, and (3) recurrent major depressive episodes. In addition, private medical records from the Kaiser Permanente Hospital show that in September 1995, the appellant received medical treatment after it was determined that he was actively drinking, actively thinking of suicide, and suffering from depression. The Board observes that outpatient treatment records from the Los Angeles VAMC show that in January 1997, the appellant was hospitalized. At that time, the appellant's wife brought him to the hospital because she could no longer deal with his alcohol dependence or his irritable mood. She indicated that he had started to act violently towards her and that he had physically attacked her the night of his admission. Upon mental status examination, the examiner noted that the appellant suffered from delusions of worthlessness and suicidal ideation. The appellant had a "flight of ideas," and his insight and judgment were impaired. The appellant was diagnosed with the following: (Axis I) alcohol induced mood disorder versus borderline personality disorder, mixed episode with comorbid alcohol dependence, (Axis II) deferred, questionable borderline personality disorder, (Axis III) alcoholism, (Axis IV) unemployment, and (Axis V) a GAF score of 20. The Board notes that during the appellant's hospitalization, the appellant complained that he had heard voices from his friends from Vietnam. The records also reflect that the appellant had trouble sleeping with frequent early night awakenings and inability to return to sleep or relax. As previously stated, in the appellant's May 1997 hearing, the appellant testified that he received therapy for his PTSD twice a week. (T.2). The appellant stated that he experienced flashbacks of his Vietnam experience everyday, and he had nightmares at least twice a week. (T.2,3,4). He indicated that he was depressed "most of the time" and that he was suspicious of people. (T.4,9). According to the appellant, although he had never tried to kill himself, he had thought about it a lot. (T.5). The Board further observes that the outpatient treatment records from the Sepulveda VAMC show that in April 1997, the appellant complained that he was depressed and anxious. At that time, he indicated that he continued to have flashbacks and nightmares of his Vietnam experience. According to the appellant, he had poor sleep patterns, loss of appetite, and he heard voices of his friends from Vietnam. The appellant was diagnosed with the following: (Axis I) PTSD, major depressive disorder (MDD), history of alcohol abuse, (Axis IV) facing sexual identity issues, and (Axis V) GAF score of 55 to 60. The evidence of record shows that the appellant has a well documented history of PTSD, and that his PTSD symptoms have included, among others, depression, sleep difficulties, anxiety, an exaggerated startle response, suicidal ideation, flashbacks, nightmares, and unprovoked irritability with periods of violence. Therefore, in light of the above, and resolving all doubt in the appellant's favor, the Board finds it reasonable to conclude that the symptomatology associated with the appellant's service-connected PTSD more nearly describes that of a 70 percent rating under the old criteria of Diagnostic Code 9411 (which were in effect through November 6, 1996), as well as the amended criteria of Diagnostic Code 9411 (which became effective from November 7, 1996). See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In so doing, such a disability picture is not viewed as indicative of total impairment of social and industrial capabilities. The evidence of record shows that the appellant has a long standing marriage and that he has relationships with some of his children. In addition, the outpatient treatment records from the Sepulveda VAMC show that in March 1997, the appellant underwent a psychodiagnostic assessment. At that time, upon mental status evaluation, the examiner stated that there were no indications of any type of thought disorder, and the appellant's thought process was linear and goal directed with no tangentiality, circumstantiality, or other pathology. The appellant demonstrated a full range of appropriate affect and, despite expressing some appropriate anxiety, he was euthymic. There was no indication of any suicidal or homicidal ideation and there was no evidence of any delusional material. In addition, the Board notes that in the appellant's May 1997 hearing, the appellant stated that although he was unemployed, he looked after his house which included doing the dishes and shopping. Therefore, in light of the above, while the appellant's psychiatric disorder results in severe disability, the clinical findings and information on repeated examinations do not indicate that the assignment of an evaluation in excess of 70 percent under the previous criteria of Diagnostic Code 9411 (effective through November 6, 1996), is warranted. Furthermore, to warrant a 100 percent evaluation under the emended criteria of Diagnostic Code 9411 (effective from November 7, 1996), it must be shown by the evidence of record that there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130 (1997). This type of symptomatology is not shown in the appellant's case. The Board notes that 38 C.F.R. § 4.16(c) was deleted from the rating schedule, also effective November 7, 1996, with the amendments for mental disorders. Section 38 C.F.R. § 4.16(c) would be used in the appellant's case since his claim for an increased rating was filed before the regulatory change occurred. Under 38 C.F.R. § 4.16(c), total disability ratings for compensation are provided if the only compensable service-connected disability is a mental disorder assigned a 70 percent evaluation, and such mental disorder precludes the veteran from securing or following a substantially gainful occupation. In such cases, the mental disorder shall be assigned a 100 percent evaluation under the appropriate diagnostic code. Id. In this case, the appellant has a mental disorder herein evaluated as 70 percent disabling. If the PTSD precludes the veteran from securing or following a substantially gainful occupation, 38 C.F.R. § 4.16(c) entitles the veteran to a 100 percent schedular rating. In the instant case, the evidence of record shows that the appellant's PTSD has interfered with his ability to work with other individuals. In the appellant's May 1997 hearing, the appellant testified that he last worked in 1992. (T.2). The appellant testified that he could no longer work because he was always in a state of panic, anxiety, and trauma. (Id.). He stated that when he was working, he would argue and fight with his co-workers. (T.2,3). However, upon a review of the record, the Board notes that in the appellant's September 1996 statement, the appellant indicated that since his discharge from the military, he had held numerous jobs including working as an apartment doorman, bartender, lumberman, theater employee, hair stylist, and "prop" person." In addition, the appellant noted that he had been employed as an industrial film worker and that he earned $1,000 for one day of work. He further reported that he had worked intermittently as a movie extra and a "day player." According to the appellant, his movie jobs averaged one day job every two years. Moreover, the Board observes that in the appellant's September 1996 VA psychiatric evaluation, the appellant noted that he had an erratic work history and that he was fired on numerous occasions because of his alcohol abuse. Therefore, although the appellant's only compensable service-connected disability is a mental disorder, PTSD, assigned a 70 percent evaluation, it is the Board's opinion that, in light of the above, the appellant's PTSD does not preclude him from securing or following a substantially gainful occupation. Accordingly, 38 C.F.R. § 4.16(c) is not for application. B. Entitlement to service connection for (1) bilateral hearing loss, and (2) tinnitus. I. Factual Background The appellant's service medical records show that in July 1965, the appellant was treated after complaining of ringing in his left ear. The records do not include a diagnosis for the appellant at that time. The remaining records are negative for any complaints or findings of hearing loss or tinnitus. The appellant's separation examination, dated in December 1966, reflects that at that time, in response to the question as to whether the appellant had ever had or if he currently had any ear trouble or running ears, the appellant responded "no." The appellant's ears were clinically evaluated as "normal." The audiological examination showed that at 500, 1,000, 2,000, and 4,000 hertz, hearing in the right ear was 20, 10, 15, and 10 decibels, respectively (American Standards Association units converted to International Standards Organization units). In the left ear for the same frequencies, his hearing was 25, 10, 15, and 10 decibels (American Standard Association units converted to International Standards Organization units). The appellant's DD Form 214, Report of Separation from the Armed Forces of the United States, shows that he served on active duty from January 1965 to January 1967. The report reflects that the appellant's Military Occupational Specialty (MOS) was as an infantry "ind. fire. crmn." According to the records, the appellant received the Parachutist's Badge, the Armed Forces Expeditionary Medal, the Expert (Rifle) Combat Infantryman's Badge, the National Defense Service Medal, the Expert (4.2 Mortar) Medal, the Expert (81MM Mortar) Medal, and the Republic of Vietnam Campaign Medal. Outpatient treatment records from the VA Medical Center (VAMC) in Sepulveda, California, from March 1980 to January 1983, show that in May 1980, the appellant underwent audiometric testing. At that time, the appellant was complaining of decreased hearing in his left ear. The audiologic evaluation showed that in regards to the appellant's right ear, his hearing was within normal limits at 250 to 3,000 Hertz, with mild hearing loss at 4,000 to 8,000 Hertz. In regards to the appellant's left ear, his hearing was within normal limits at 250 to 1,500 Hertz, with moderate to severe hearing loss at 2,000 to 8,000 Hertz. Speech discrimination percentages were 96 percent at 45 decibels in his right ear, and 90 percent at 45 decibels in his left ear. The diagnoses included the following: (1) mild high frequency sensorineural loss in the right ear, above the speech frequencies, and (2) moderate high frequency sensorineural hearing loss of the left ear, commencing at the upper limits of the speech range. The examining physician noted that the appellant's speech discrimination was "good" under ideal listening conditions. The remaining records show treatment for unrelated disorders. In October 1996, the appellant underwent a VA audiometric evaluation. At that time, he stated that he had had bilateral hearing loss and tinnitus since 1965. He indicated that during service, he was exposed to gun fire and mortars which caused him to develop bilateral hearing loss and tinnitus. According to the appellant, at present, he had difficulty hearing when he was in a crowd or speaking on a telephone. The appellant further revealed that his current tinnitus was bilateral and severe. He noted that in regards to frequency and loudness, his tinnitus was periodic, and one ear was medium pitched and the other ear was high pitched. The physical examination showed that the ears had intact tympanic membranes and canals. Examination of the nose revealed midline nasal septum with no polyps or infections, and examination of the pharynx showed normal palate with no growths or infections. Examination of the neck revealed midline trachea with no palpable nodes and no enlargement of the thyroid glands. The audiometric examination revealed that the appellant had pure tone air conduction threshold levels in the right ear at 500, 1,000, 2,000, 3,000, and 4,000 Hertz as follows: 15, 20, 55, 60, and 70 decibels, respectively, with a pure tone average of 51 decibels. In the left ear for the same frequencies, he had pure tone air conduction threshold levels of 15, 20, 80, 75, and 75 decibels, with a pure tone average of 63 decibels. Speech discrimination percentages were 78 percent in his right ear and 74 percent in his left ear. The examiner interpreted the results as showing bilateral sensorineural hearing loss. In May 1997, a hearing was conducted at the RO. At that time, the appellant testified that while he was in the military, his MOS was as a "mortar man." (T.8). He stated that because of his MOS, he was exposed to a lot of noise and he was in "4.2 mortars which [were] eight bombs." (Id.). The appellant reported that he experienced acoustic trauma for approximately 16 months. (Id.). He indicated that upon enlistment, he underwent training and then he was sent to Okinawa. (T.8,9). According to the appellant, while he was stationed in Okinawa, he told his company commander that he was experiencing hearing problems and he was sent to the dispensary. (T.9). The appellant noted that at that time, he was given a hearing test and he was diagnosed with bilateral hearing loss. (Id.). He stated that he was told that his hearing loss would be taken "care of" once the Vietnam War was over. (Id.). According to the appellant, he was then sent to Vietnam. (Id.). The appellant indicated that he was involved in fire fights which were "terrifying" because he could not tell the direction of the fire. (Id.). He reported that during his separation examination, he did not indicate that he was having hearing problems and/or suffering from tinnitus because he wanted to be discharged as quickly as possible. (T.9,10). In the appellant's May 1997 hearing, the appellant testified that following his separation from the military, he did not seek medical treatment for his hearing problems or his tinnitus until the 1980's at which time he went to a "lip reading" school at the Sepulveda VAMC. (T.9). The appellant revealed that at present, he had trouble hearing conversations and he could not hear the television. (Id.). He noted that since his discharge, he had not suffered from any head injuries, and he had not been exposed to loud noises. (T.10). The appellant stated that he was not currently receiving any medical treatment for his hearing problems. (T.11). II. Analysis The threshold question that must be resolved with regard to a claim is whether the appellant has presented evidence of a well-grounded claim. A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. An allegation of a disorder that is service connected is not sufficient; the appellant must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. See Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Lay assertions of medical causation cannot constitute evidence to render a claim well grounded; if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Grottveit, 5 Vet. App. at 93. Service connection may be established for disability resulting from injury or disease incurred in service or for a preexisting injury or disease that was aggravated by service. 38 U.S.C.A. § 1110. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1998). For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1998). To summarize, the appellant contends, in essence, that during service, he was exposed to loud noises while he was performing his MOS as a "mortar man." The appellant maintains that because of the acoustic trauma he experienced while he was in the military, he developed bilateral hearing loss and tinnitus which have continued to the present. In this regard, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. Layno v. Brown, 6 Vet. App. 465 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). However, when the determinative issues involves a question of medical causation, only individuals possessing specialized training and knowledge are competent to render an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The evidence does not show that the appellant possesses medical expertise, nor is it contended otherwise. Therefore, his opinion that his bilateral hearing loss and tinnitus are related to service is not competent evidence. In the instant case, based on the results of the appellant's October 1996 VA audiometric evaluation, the Board acknowledges that the appellant has presented evidence of current bilateral sensorineural loss that is considered a disability for VA purposes. See 38 C.F.R. § 3.385. Moreover, the Board further notes that the appellant currently suffers from tinnitus. However, despite any current hearing loss and/or tinnitus, there is no competent medical evidence of record that establishes a nexus, or link, between any current impaired hearing and/or tinnitus, and the appellant's military service. The Board notes that even accepting as true the appellant's contentions that he was exposed to acoustic trauma in service and that he developed tinnitus, his claims still would not be well grounded, as the missing element in this case is competent medical evidence of a nexus, or link, between any current hearing disorder and/or tinnitus, and an incident of the appellant's military service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); Cohen v. Brown, 10 Vet. App. 128, 138 (1997); Libertine v. Brown, 9 Vet. App. 521, 524 (1996). Although the appellant has stated that his current hearing loss and tinnitus are related to service, the evidence does not show that the appellant possesses medical expertise, nor is it contended otherwise. Therefore, without supporting medical evidence of a nexus between the appellant's current hearing loss and/or tinnitus, and service, the appellant's statement is insufficient to render his claims well grounded. See Grottveit, 5 Vet. App. 91, 93 (lay assertions of medical [etiology] cannot constitute evidence to render a claim well grounded under section 5107(a)); Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995) (evidentiary assertions may not be accepted as true when the fact asserted is beyond the competence of the person making the assertion). Thus, without competent medical evidence of a causal relationship between any current hearing loss and/or tinnitus, and an in- service incident, the appellant has not presented well grounded claims for service connection for bilateral hearing loss, or service connection for tinnitus, and his claims must be denied. The Board recognizes that these claims are being disposed of in a manner that differs from that used by the RO. The RO denied the appellant's claims on the merits, while the Board has concluded that the claims are not well grounded. However, the Court has held that "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well grounded analysis." See Meyer v. Brown, 9 Vet. App. 425, 432 (1996). Likewise, the Board finds that the RO has advised the appellant of the evidence necessary to establish a well grounded claim. Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995). ORDER An increased rating for PTSD is granted, to the extent noted, subject to the provisions governing the payment of monetary benefits. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. DEBORAH W. SINGLETON Member, Board of Veterans' Appeals Department of Veterans Affairs