Citation Nr: 1124940 Decision Date: 06/30/11 Archive Date: 07/06/11 DOCKET NO. 08-22 963 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial rating higher than 30 percent disabling for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T.S. Willie, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1968 to December 1969. This matter is on appeal from the North Little Rock, Arkansas, Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in March 2009. A transcript of the hearing is of record. This case was remanded by the Board for further development in June 2009. FINDINGS OF FACT 1. PTSD is manifested by intrusive thoughts, nightmares, depression, social isolation, irritability, flashbacks, memory loss and concentration problems, panic attacks and avoidance. 2. The Veteran's service-connected disability does not render him unable to obtain and retain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a 50 percent rating, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.130; Diagnostic Code (DC) 9411 (2010). 2. The criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16, 4.19 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, his claims. PTSD Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2010). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Here, the Board finds that the Veteran's disability has not significantly changed and that a uniform rating is warranted. In the rating decision on appeal, the Veteran was awarded service connection for PTSD and granted an evaluation of 30 percent. PTSD is rated under DC 9411, which is evaluated under the general rating formula for mental disorders. See 38 C.F.R. § 4.130. The Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under-or over-inclusive. The Secretary's 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. Instead, the rating specialist 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 DSM-IV. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). The General Rating Formula provides a 30 percent evaluation when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted where there is 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 or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 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); inability to establish and maintain effective relationships. 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. In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 31 to 40 is assigned where there is 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. A score of 41-50 is assigned where there are 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 score of 51-60 is assigned where there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflict with peers or co- workers). Id. A score of 61-70 is indicated where there are 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, has some meaningful interpersonal relationships. Id. The Veteran has appealed the denial of the assignment of a 30 percent evaluation for PTSD. The current rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. To warrant a higher evaluation the evidence must show occupational and social impairment with reduced reliability and productivity. Based on the evidence presented, the Board finds that the Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 50 percent rating than that contemplated by a 30 percent rating under DC 9411. A majority of the type of criteria contemplated for a 50 percent rating under DC 9411 have been demonstrated. In this regard, the Veteran has reported intrusive thoughts, nightmares, depression, social isolation, irritability, flashbacks, and avoidance. He related having significant anxiety at times and that he had periods of depression every few days in which he stayed in the house all day. He has also reported difficulty concentrating, memory loss and problems with anger. At times, he has had suicidal ideation but without intent or plan. Via various statements, he has expressed that he and his wife did little together, and that he had difficulty going to restaurants and sporting events to watch his grandchildren. Although in September 2006 the Veteran stated that he got along well with his wife, he also related that he got angry with her but he denied physical aggression. According to his wife, he had nightmares about Vietnam. She stated that he yelled at her, hit her on a couple of occasions and had always been moody. She further related that he angered easily, did not like crowds, only had a few close friends, and that they avoided places with a lot of people. She has stated that he was hard to get along with and that they had a difficult relationship at best. She also stated that the Veteran sat at home in the garage for most of the day normally by himself. In December 2007, the Veteran's supervisor related that he worked as a group leader and that he had been in charge of a group of about 35 people. He stated that in the last two years of his employment the Veteran had a lot of problems and that he had to talk to the Veteran about his attitude several times. He related that the Veteran was not getting along with people and that a lot of things got on the Veteran's nerves, and that he seemed depressed. In August 2008, he noted that he retired related to the fact that he could not perform his job due to PTSD. In his December 2007 VA examination, the Veteran reported being married but that he and his wife did separate things. He related that he worked for 36 years until he retired in 2007. There he served as a group leader but reported that he retired early because of problems with co-workers. He reported that there were times when he would "holler" at people and that he thought he should quit before being fired. He related that he had to work by himself as he found it difficult to get along well with others. Since retiring, he did odd jobs to include mowing yards during the summer and small carpentry jobs. The Veteran reported that he seldom went out to eat because he did not like crowds. He seldom went to ball games but tried to because of his grandchildren. During his March 2009 hearing, the Veteran related that without his PTSD medication he could not make it. He stated that his relationship with his family was not real great and that he and his wife did not sleep together all the time because of his nightmares. He related that he did not socialize because he did not like to be around a crowd of people and that he only had a few friends. He described himself as irritable or having periods of violence, and he expressed problems with remembering simple tasks. He stated that he had a hard time remembering the names of his grandchildren at times, had periods of disorientation, got mad easily, had panic attacks, thoughts of suicide and nightmares. He also related that he quit his job because he could not get along with people and that he was afraid that he might get fired. In the January 2010 VA examination, the Veteran reported problems with nightmares, intrusive thoughts, anger, getting along with others, depression, memory and concentration. He related that he did not like to be around people generally for any length of time and that he did not like crowds of people. Examination revealed on delayed recall task he could only recall two of three words he had been asked to remember and he was unable to complete his serial sevens. A GAF score of 55-60 was assigned. The examiner related that the Veteran continued to present with signs and symptoms of PTSD. Based on the above evidence, the Board finds that a 50 percent evaluation is warranted. The evidence shows panic attacks, impairment of memory, disturbance of mood, and difficulty in establishing and maintaining effective work and social relationships. These findings justify a higher evaluation. Furthermore, while an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned (38 C.F.R. § 4.126), it is notable that for the period considered in this appeal the Veteran's GAF scores have ranged from 50 to 60. The Board notes that a GAF score of 50 was assigned in April 2006 which is indicative of serious symptoms; however, the majority of his GAF scores have shown moderate symptomatolgy. As such, the GAF scores are consistent with the Veteran's PTSD symptomatology and the assignment of a 50 percent rating. Stated differently, the medical and lay evidence as well as the GAF scores establish that there is occupational and social impairment with reduced reliability and productivity. Although the Board finds that the Veteran's PTSD more nearly approximates the criteria for a 50 percent evaluation, a 70 percent rating is not warranted as there is no showing of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. In this regard, although he reported problems at work when he was employed, the Board notes that he nevertheless worked for 36 years before retiring. He has related that since retiring he worked in his garden, mowed yards and fished to keep busy. He has also expressed that he started getting together with a few other veterans once a week. In March 2008, he reported that he was managing his anger and that he attended a couple of games to see his granddaughter who is a cheerleader. Although he related that he did not stay for the game, the Board notes that he nevertheless attended a couple of games. In his examinations, the Veteran reported that he maintained a relationship with his siblings and that he continued to maintain contact with his children and visited his grandchildren. Although he spent most of the day watching television, he did household chores, cooked and during the summer tended the garden. He did not belong to any clubs or groups but he had a few close friends. He and his wife got together with these friends occasionally for dinner. They also traveled with these friends a couple of times a year to the lake where they stayed and fished. The Board notes that the Veteran has remained married and has contact with his siblings, children and grandchildren. He also has a few friends. Clearly, he has some ability to establish and maintain effective relationships. Furthermore, examinations reveal that he appeared well groomed and casual. His speech was coherent and discernible, and mood and affect appeared appropriate and congruent. He was also oriented. Although he was unable to complete serial sevens and could only recall two of the three words he had been asked to remember, he spelled the word "word" backwards correctly and had no difficulty with immediate recall task. Also, there were no delusions and/or hallucinations present in his examinations. Here, the evidence is devoid of a showing of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as obsessional rituals which interfere with routine activities; speech 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, and the inability to establish and maintain effective relationships. Although at times he has had suicidal thoughts, his suicidal ideation has been intermittent at most and without intent or plan. Also, while the Veteran has reported irritability and periods of violence, there is no showing of unprovoked irritability with periods of violence. Further, he has reported having periods of disorientation and that occupational impairment has been shown by the record. However, such findings do not warrant a 70 percent evaluation when all the other manifestations are considered. The Board has considered the Veteran's statements that his disability is worse than evaluated. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). In sum, the appellant's symptoms are more characteristic of a disability picture that is contemplated by a 50 percent rating and no more. The Board has also considered referral for an extraschedular rating. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, the evidence does not show any unusual or exceptional circumstances, such as marked interference with employment (i.e., beyond that already contemplated in the assigned evaluation) or frequent periods of hospitalization related to the service-connected disability at issue, that would take the Veteran's case outside the norm so as to warrant an extraschedular rating. Specifically, the rating criteria reasonably describe his disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. Consequently, referral to the Under Secretary for Benefits or the Director, Compensation and Pension Service, under 38 C.F.R. § 3.321 is not warranted. TDIU The Veteran has appealed the denial of TDIU. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16(b). Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board observes that a claim for TDIU is, in essence, a claim for an increased rating. Norris v. West, 12 Vet. App. 413, 420- 21 (1999). A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. The record indicates that the Veteran is currently service- connected for PTSD, evaluated as 50 percent disabling. This is his only service connected disability. The 50 percent rating does not meet the minimum percentage rating required for consideration of assignment of TDIU. 38 C.F.R. § 4.16(a). Therefore, TDIU on a schedular basis cannot be established. As such, the Board will next address whether TDIU is warranted on an extraschedular basis. The Board now must determine whether the Veteran's service connected disability preclude him from obtaining or maintaining substantially gainful employment consistent with his education and occupational experience. In this case, the Board is presented with positive and negative evidence. The positive evidence includes the December 2007 VA examination in which the Veteran reported that he worked for 36 years for the same company until he retired in 2007. There he served as a group leader but reported that he retired early because of problems with co-workers. He reported that he thought he should quit before being fired. He related that he had to work by himself as he found it difficult to get along well with others. Also, in December 2007, the Veteran's supervisor related that the Veteran worked as a group leader and that he had been in charge of a group of about 35 people but that in the last two years of his employment he had a lot of problems. His supervisor stated that he had to talk to him about his attitude several times and he was not getting along with people. In August 2008, it was noted that he retired related to the fact that he could not perform his job due to PTSD. The Board also notes that, in two separate statements, the Veteran's friends D.R. and J. G. related that after the Veteran retired they worked with him but had to stop to save the friendships. Via various statements the Veteran has reported that he quit his job because he could not get along with people and that he was afraid that he might get fired. He related that he has to work by himself as he finds it difficult to get along with others. He contends that he is unemployed and has been unable to find employment. The Board has considered such statements in conjunction with the evidence of record. However, the Board is presented with convincing negative evidence. In this regard, the Veteran was afforded a VA examination in January 2010. During this examination, he related that he had not been gainfully employed for the last two years. It was noted that post retirement he tried to work for friends but because of his anger he found it difficult to get along with them and had to stop working with them. After examination, the VA examiner opined that "it is less likely as not that the Veteran does not meet the criteria of un-employability based solely upon his service connected condition of post-traumatic stress disorder." Further, the VA examiner stated that the Veteran expressed that he has problems with temper and anger and that such caused him to take early retirement after being employed for 36 years by the same company. The VA examiner also stated that the Veteran expressed that he was concerned about being fired if he got into a fight or argument with one of his co-workers and that since retirement he tried to work with one of his friends but could not because of problems that would occur between him and his friend. The VA examiner then went on to state that the Veteran however continued to maintain a fairly active lifestyle. He related that the Veteran was able to care for his home and maintained some friendships and engaged in activities such as fishing trips and fish fry's. Based on the evidence presented, the Board finds that the preponderance of the evidence is against the claim. In this regard, the Board acknowledges the Veteran's contentions that his PTSD renders him unemployable. However, it has not been shown that he is unable to secure and follow a substantially gainful occupation by reason of his PTSD. The Veteran is retired. While the record indicates that the Veteran angers easily and that he cannot work with his friends, it does not indicate that his PTSD renders him unemployable. Furthermore, the VA examiner has opined that the Veteran's PTSD does not render him unemployable. Although he argues that the VA opinion is ambiguous, the Board find that, while it was could have been better worded, the examiner nevertheless rendered an opinion that the Veteran's PTSD did not preclude employment. The Board acknowledges the Veteran's contentions that he is unable to get along with others and that he has to work by himself. However, while PTSD clearly interferes with his ability to interact with others, any schedular rating implies some degree of interference with employment. The evidence in this case does not demonstrate marked interference with employment, or any type of interference that is outside the bounds of the rating criteria. The Board is also mindful that throughout this appeal the Veteran has been unemployed and that he has been unemployed since 2007. However, the sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. Although the Veteran genuinely believes that he cannot secure or follow a substantially gainful occupation as a result of his service-connected PTSD, the more probative evidence is against the claim. The Board notes that, as a lay person, lacking in medical training and expertise, the Veteran cannot provide a competent opinion on a matter as complex as whether he can secure or follow a substantially gainful occupation as a result of his service connected disability and that his views lack probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds that any probative value of the Veteran's own conclusion is far outweighed by that of the opinion provided by the VA medical professional, who examined the Veteran and reviewed the claims folders, and found that the Veteran's service- connected PTSD does not render him unemployable. In sum, the Board finds that the Veteran's PTSD does not preclude substantially gainful employment. Therefore, a grant of TDIU is not warranted on a scheduler or extraschedular basis. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, a letter satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) was sent to the Veteran in November 2007 prior to the initial RO decision that is the subject of this appeal. The letter informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Moreover, with respect to the Dingess requirements, the Veteran was given notice of what type of information and evidence he needed to substantiate his claim. The Board notes that he is challenging the disability evaluation assigned following the grant of service connection for PTSD. In Dingess, the U.S. Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, VA's duty to notify in this case has been satisfied. Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2010). After a careful review of the file, 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). First, the RO has obtained VA outpatient treatment records. Next, specific VA compensation and pension examinations pertinent to the issue on appeal were obtained in December 2007 and January 2010. The Board notes that this case was remanded in June 2009 with the directive to schedule the Veteran for a VA compensation and pension examination. The Veteran was afforded such examination in January 2010. The Board finds that the examination was adequate as it reflects a pertinent medical history, review of the documented medical history, clinical findings and a diagnosis. Significantly, neither the Veteran nor his representative has 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 is required to fulfill VA's duty to assist 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 An evaluation of 50 percent disabling, but no more, for PTSD is granted, subject to the controlling regulations applicable to the payment of monetary benefits. TDIU is denied. ______________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs