Citation Nr: 0811678 Decision Date: 04/09/08 Archive Date: 04/23/08 DOCKET NO. 05-28 652 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for chest disability. 2. Entitlement to an increased rating for a chronic adjustment disorder, currently rated at 70 percent disabling. ATTORNEY FOR THE BOARD A.G. Alderman, Associate Counsel INTRODUCTION The veteran had active military service from August 1995 to July 1999 and from December 2000 to August 2003. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, that denied service connection for chest pain and granted service connection for adjustment disorder with mixed emotional features (adjustment disorder). The case was subsequently transferred to the Phoenix, Arizona RO. In February 2007, the Phoenix, Arizona RO granted a 70 percent disability rating for the veteran's adjustment disorder, effective April 2006. FINDINGS OF FACT 1. The veteran does not have a chest disability related to service. 2. The veteran's adjustment disorder is not manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. A chest disability was not incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131 (West Supp. 2005); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 2. The criteria for a 100 percent disability rating for a chronic adjustment disorder have not been met. 38 U.S.C.A. § 1155 (West Supp. 2005); 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9440 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran seeks service connection for chest pain, or costochondritis. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In addition, certain chronic diseases, such as arthritis and hypertension, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West Supp. 2005); 38 C.F.R. §§ 3.307, 3.309 (2007). In general, service connection requires: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). With respect to the veteran's claim for service connection for a chest disorder, the veteran's service medical records show that he was treated in February 1997 for complaints of chest pain. His radiology report indicated that the veteran's chest was normal. The veteran was also treated in March 1997 for complaints of chest pain, which he had been experiencing for about a month. He was assessed as having costochondritis with an upper respiratory infection. In February 1998, the veteran again sought treatment on two occasions for chest pain. At his appointment on the 20th of February, the veteran complained of pain when coughing, deep breathing, laughing, and bending in certain positions. He had been experiencing pain for about 2 days. He was assessed as having either epigastric reflux or costochondritis. A few days later, he was diagnosed with mild upper respiratory infection and mild costochondritis. Subsequent to service, August 2003 VA outpatient records indicate that the veteran complained of chest pain secondary to being restrained while in the hospital. At an appointment in September 2003, the veteran indicated that he still had some chest discomfort that is worse when lying down, and increases when sneezing and coughing. It was noted that the veteran had muscle skeletal chest wall pain for several weeks after having his stomach pumped, which resulted in a chest wall injury. The veteran was given a differential diagnosis of chest pain. The veteran had a VA exam in June 2004. At that time, the VA examiner noted that the veteran had a history of an episode of pneumonitis in 1997 with chest pain. Both conditions resolved with treatment for the pneumonitis. The examiner also noted the history of costochondritis. The veteran indicated that the costochondritis dated back to the early 1990s, and that in 2002 while lifting something, he recalled a tearing sensation with sharp pain in the pectoralis. He said he had felt tenderness along the chest wall in the axilla, which extended to the pectoral muscle area. The chest exam was normal. The examiner noted that there was no costochondral tenderness or tenderness in the left axilla or in the left pectoral area to direct palpation during the VA exam. The Board must find that, overall, the service medical records provide evidence against this claim, failing to indicate a chronic chest disorder. More importantly, the veteran has not submitted any evidence showing that he currently has a chest disability. The Board reviewed VA treatment records; however, the records do not indicate that the veteran suffered or currently suffers from a chronic chest pain stemming from an in service injury or aggravation of a pre-existing disability. Thus, the post-service medical records provide highly probative evidence against the appellant's claim. In addition to the medical evidence, the Board has considered the veteran's lay statements in support of his claim. However, as a layperson, without the appropriate medical training and expertise, the veteran is not competent to provide a probative (persuasive) opinion on a medical matter, such as the etiology of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492 494-95 (1991) (laypersons are not competent to render medical opinions). Thus, the veteran's personal opinion that his chest disability is related to service is not a sufficient basis for awarding service connection. The Board finds that the service and post-service treatment (or lack of treatment) outweighs his statements at this time. While the veteran may have, at times, chest pain (due to, for example, an episode of pneumonitis) it is important for the veteran to understand that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a "disability" for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In conclusion, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to service connection for a chest disorder, costochondritis. In reaching this decision, the Board has considered the doctrine of reasonable doubt. However, because the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b). In short, in absence of competent medical evidence showing a current chest disorder, the veteran's claim must be denied. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that compensation may only be awarded to an applicant who has a disability existing on the date of the application, and not for a past disability); Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in the absence of proof of the presently claimed disability, there can be no valid claim). Increased Rating Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2007). If two evaluations are potentially applicable, 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. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original rating remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The veteran asserts that he is entitled to a higher rating for his service-connected adjustment disorder, currently evaluated as 70 percent disabling under DC 9440, chronic adjustment disorder. 38 C.F.R. § 4.130. Under DC 9440, 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 work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent rating is indicative of 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 of names of close relatives, own occupation or own name. Id. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to symptoms provided in that diagnostic code. Id. at 443. Instead, the VA is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, as revised in the 1994, fourth edition (DSM-IV). Id. If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to what would be caused by the symptoms listed in a particular diagnostic code, the appropriate, equivalent rating will be assigned. Id. In assessing the evidence of record, the Board has reviewed the veteran's Global Assessment of Functioning (GAF) score. The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness."DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH ED, American Psychiatric Association (1994) (DSM-IV), p.32; 38 C.F.R. §§ 4.125(a), 4.130 (2006). GAF scores ranging from 71 to 80 reflect that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) and result in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well. GAF scores between 51 and 60 are reflective of moderate symptoms (e.g., flat effect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation, or school functioning, e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. A GAF score in the 31 to 40 range indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2007). In August 2006, the veteran underwent a VA exam. The examiner reviewed the claims file, and specifically mentioned a psychological evaluation from April 2006, discussed herein. The veteran's history mentioned his placement in learning disabled classes in grade school and high school, and the examiner indicated that after speaking to the veteran, that it was his opinion that it is more likely than not that the veteran's learning disability has to do with concepts. The veteran is capable of completing tasks, such as building an object, if he is shown how to build it as opposed to having to read written directions on how to build it. At the time of the exam, the veteran was taking college courses; however, the veteran admitted to having problems in two classes. The examiner indicated that it is more likely than not that the veteran's difficulty is based on his reading capability. The veteran was not and had not been employed during 2006. The VA examiner indicated that it is more likely than not that the veteran could be employed in only very menial tasks, such as dish washing. The examiner indicated that the veteran's symptoms are constant, unremitting, and severe to a point where he is not employable. His last job ended in June 2005. His symptoms have caused the veteran to have no social life and only one friend, as he distrusts people, especially when they point at him or touch him. He is uncomfortable with touching, even if it is done as a sign of compassion. The veteran still lives with his parents and sister, and on a typical day he will sleep until noon, check email, and then go to school He is often tardy for school; however, he gets along in the classroom, likely due to the small class size, and upon returning home, he thinks, rests, and works on 2 of his inventions. The veteran experienced no impairment of thought process or communication. He had no delusions, hallucinations, inappropriate behavior, or suicidal or homicidal thoughts. His memory was good and he was oriented as to person, place, and time. The veteran's speech was normal, he suffered no panic attacks, he was slightly depressed, and did not have impaired impulse control. The examiner indicated that his diagnosis is adjustment disorder with mixed anxiety and depressed mood, as a result of his attention deficit disorder. The GAF score assigned for the year was 50, with serious impairment in social, occupational, and school functioning, no friends, and unable to keep a job. At the VA exam in August 2005, the veteran reported symptoms of depressed mood, poor sleep, decreased interest and motivation, attentional problems, and difficulties with impulsive behavior; intense anger; abandonment; unstable relationships, poor sense of self; and suicidal behavior with attempts. The veteran reported that the severity of the symptoms was moderate to high and that the duration and frequency of symptoms has been chronic with no remission. It was noted that the veteran was not working but that he was about to start advanced schooling. The veteran reported having very few friends and isolating himself at home playing video games. The veteran also reported a history of marijuana use. The examiner indicated that there was no impairment in thought process or communication. The veteran had no hallucinations or delusions, but reported ongoing suicidal and homicidal ideation without plan or intent. He was able to maintain activities of daily living and personal hygiene. He was also oriented to person, place, and time. He had no significant memory loss or impairment, or did he have obsessive or ritualistic behavior. His speech was normal. The examiner noted the presence of depression and sleep impairment as well as impaired impulse control. The examiner noted that the veteran tends to isolate himself and has difficulty appropriately interacting with others. Also noted was that the veteran does not engage in many social activities, but he is capable of basic activities of daily living. The veteran also has great difficulty in meeting family responsibilities as well as work demands and responsibilities. The VA examiner diagnosed the veteran with major depressive disorder, recurrent of moderate severity, with borderline personality disorder. A GAF score of 50 was assigned. During the August 2003 VA exam, the examiner noted that the veteran was living with his wife and children, and doing activities with the children. The examiner noted that the veteran was not homicidal or suicidal, but had some mild depression and mild anxiety. He was assigned a GAF of 60. In November 2004 and April 2006, the VA referred the veteran for private psychological evaluations. Both were conducted by the same psychologist. In the April 2006 report, the examiner indicated that since the veteran's November 2004 evaluation, the veteran had shown marked instability in his school performance as well as his ability to provide for himself. As of February 2006, the veteran was in school and making A's and B's in his courses. The medical provider opined that the veteran functions in the average range of intelligence and that he would require significant accommodations with his schooling to advance. He opined that the veteran is not likely to be employed n the near future as he suffers a significant level of paranoid thinking which makes it difficult to interpret reality correctly. The veteran imputes negative intention and hostile feelings from others and projects his own disturbed thoughts and emotions onto others. Further, there are clear clinical signs of the onset of a delusional paranoid disorder with primary jealousy elements. The veteran has a history of suicidal ideation and homicidal threats, and though he insists that he is under control, the medical professional indicated that the veteran needs a higher level of psychiatric intervention. A GAF score of 37 was assigned. In November 2004, the VA referred the veteran for a private psychological evaluation. It was noted that the veteran had learning disabilities but would benefit from vocational- technical training programs. The examiner noted the veteran's emotional and personal issues plaguing the veteran. No GAF score was assigned. Based upon the evidence, the Board finds that the medical evidence does not meet the requirements for a 100 percent rating under DC 9440. For a 100 percent rating, the evidence must show 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; disorientation to time or place; memory loss of names of close relatives, own occupation or own name. Id (emphasis added). The evidence indicates that the veteran isolates himself and admits that he has one friend, and has a marked distrust of people, providing the basis for the 70 percent evaluation. The evidence also shows that the veteran is engaged in college courses to advance his education and employment opportunities, that he gets along in the classroom, and that he makes good grades, all of which weighs heavily against the finding of total social impairment of 100 percent. The August 2006 VA examiner indicated that the veteran was most suited to menial tasks, such as dish washing. However, the examiner indicated that the veteran's symptoms are constant, unremitting, and severe to a point where the veteran is not employable, weighing in favor of finding total occupational impairment. However, the examiner indicated that the veteran communicates well, and that rapport with the veteran was easily established, providing evidence that in some point supports and at others refutes the veteran's claim. Importantly, neither the veteran nor his medical providers indicated that the veteran has exhibited gross impairment in his thought processes or communication, delusions, hallucinations, grossly inappropriate behavior, danger of hurting himself or others, disorientation to time or place, or an inability to perform activities of daily living, providing evidence against this claim. The Board notes that the private exam from April 2006 indicates that the veteran had the onset of delusional paranoid disorder with primary jealousy elements; however, it is important to note that the VA examiner did not make the same or similar findings in the VA exam conducted in August 2006. The Board has considered the GAF scores, and though the April 2006 score assigned by the private examiner was a 37, disability ratings are assigned based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. The GAF scores assigned in this case throughout the pendency of the appeal range from 37 to 60. The most recent score assigned is 50, which is reflective of severe symptoms; however, based upon the totality of the evidence, the Board finds that the veteran's symptoms do not show total occupational impairment and total social impairment, thus an increased disability rating is not warranted at this time. Reviewing the evidence, the Board finds that the overall disability picture for the veteran's adjustment disorder does not more closely approximate a 100 percent rating, as his symptoms do not cause total occupational and social impairment. 38 C.F.R. § 4.7. Therefore, the preponderance of the evidence against this claim. 38 C.F.R. § 4.3. Finally, the Board finds no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). That is, there is no evidence of exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, to suggest that the veteran is not adequately compensated by the regular rating schedule. VAOGCPREC 6-96. Accordingly, the Board finds that the preponderance of the evidence is against entitlement to a rating greater 70 percent for an adjustment disorder. 38 C.F.R. § 4.3. In this regard, it is important to note that the veteran was awarded a 100% total disability evaluation based on individual unemployability in October 2007. In deciding the veteran's claims the Board has considered the determination in Fenderson v. West, 12 Vet. App. 119 (1999), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period (as in this case). Id. at 126. The Board does not find evidence that the veteran's disorders should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record from the day the veteran filed the claims to the present supports the conclusion that the veteran is not entitled to additional increased compensation during any time within the appeal period, beyond that cited above. The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction, or regional office (RO). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, 22 Vet. App. 37. Here, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial RO decision by way of letters sent to the veteran in September 2003, May 2005, and March 2006 that fully addressed all four notice elements. The letters informed the veteran of what evidence was required to substantiate the claims and of the veteran's and VA's respective duties for obtaining evidence. The veteran was also asked to submit evidence and/or information in his possession to the RO. Although the notice letter was not sent before the initial RO decision in this matter, the Board finds that this error was not prejudicial to the veteran because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the veteran been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the RO also readjudicated the case by way of a rating decision and supplemental statement of the case issued in February 2007, after the notice was provided. For these reasons, it is not prejudicial to the veteran for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. VA has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA outpatient treatment records and private medical records. The veteran was afforded a VA medical examination in June 2004 and August 2006. Significantly, the veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a chest disability is denied. Entitlement to an increased rating for a chronic adjustment disorder is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs