Citation Nr: 1126397 Decision Date: 07/13/11 Archive Date: 07/19/11 DOCKET NO. 06-20 746 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). 3. Entitlement to service connection for interstitial lung disease associated with asbestos exposure. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran had active service from May 1966 to February 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in Atlanta, Georgia. In an April 2005 rating decision, the RO granted service connection for PTSD and assigned an initial 10 percent disability rating effective May 10, 2004. In an April 2006 rating decision, the disability rating was increased to 30 percent, effective May 10, 2004. The Veteran is presumed to be seeking the maximum benefit allowed by law and regulation. Thus, a claim remains in controversy where less than the maximum available benefits are awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). In a July 2007 rating decision, the RO denied service connection for interstitial lung disease associated with asbestos exposure. The Board must consider whether a TDIU is warranted. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, the issue is inferred by way of the record. The Veteran submitted additional evidence to the Board, along with a waiver of initial RO consideration of the evidence, following the last supplemental statement of the case. The Board may, therefore, consider this evidence. See 38 C.F.R. §§ 20.800, 20.1304 (2010). The issues of entitlement to service connection for interstitial lung disease associated with asbestos exposure and entitlement to a disability rating in excess of 70 percent for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appeal, the Veteran's PTSD has been productive of at least occupational and social impairment with deficiencies in most areas, such as work, judgment, thinking, and mood. 2. Resolving doubt in the Veteran's favor, his service-connected PTSD disability precludes him from securing and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a 70 percent disability rating for PTSD have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a TDIU are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.1, 4.16, 4.19 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify & Assist In this decision, the Board grants entitlement to a 70 percent disability rating for the Veteran's PTSD and remands the issue of entitlement to a disability rating in excess of 70 percent for further development. In addition, the Board grants entitlement to a TDIU. As such, no discussion of VA's duty to notify and assist is necessary. This case was remanded by the Board in October 2009 for additional development, which included securing VA examinations and additional service records. With the exception of the development discussed in the Remand below, there was substantial, if not full, compliance with the Board's October 2009 directives. Increased disability ratings Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2010); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Veteran is appealing the initial assignment of a disability rating, as such, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2010). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2010). The Veteran's PTSD is currently rated as 30 percent disabling, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 30 percent rating is warranted if the evidence shows 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted if the evidence shows 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. Id. A 70 percent rating is warranted if evidence shows 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); and an inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if evidence shows 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; and memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining whether the Veteran meets the criteria for a higher rating, the Board must consider whether the Veteran has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). 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 (2010). As relevant to this case, a GAF score of between 31 and 40 contemplates some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF score from 51 to 60 represents moderate symptoms, or moderate difficulty in social or occupational functioning. VA treatment records from May 2004 to the present show the Veteran reported symptoms of anxiety, nervousness, irritability, depression, panic attacks, hypervigilance and hyperarousal. Objective mental status examinations reveal that throughout the appeal, his mood has mostly been depressed and/or anxious, although at times it was described as sad, bright, or good. The Veteran's affect has generally been full, although at times it has been described as restricted or irritable. VA treatment notes also reveal that during the appeal, there have been no reports or findings of: suicidal or homicidal thoughts or ideation, impairment of thought process or communication, delusions, or visual hallucinations. Some auditory hallucinations were reported in March 2005. Insight and judgment have ranged from appropriate to fair. The records also reflect that at times the Veteran's grooming has been fair and other times he was found to be well-groomed. Upon evaluation in June 2006, the Veteran reported he must be told to change his clothes and to bathe. In addition, VA treatment records show that GAF scores have primarily ranged from 55 to 65. The lowest score reported was 39, in August 2004. In providing these GAF scores, VA clinicians described the Veteran's PTSD as mild. A December 2008 mental health clinic note indicated that the Veteran's socialization was 'decent.' The Veteran was afforded a VA examination in November 2004, at which time he reported symptoms of flashbacks, nightmares, avoidance, anger, hyperarousal, and short-temperedness. On mental status examination, he was noted to be casually dressed and adequately groomed. There was no impairment of thought process or communication. He was free of delusions and hallucinations, and homicidal or suicidal ideas, thoughts or plans. Ability to maintain hygiene and other of activities of daily living were fair, as long as he was reminded by his wife. He was fully oriented. Memory was intact for immediate recall. Concentration was mildly impaired. He was free of obsessive or compulsive behavior. Speech was normal. Mood was euthymic and he reported feeling anxious. The diagnosis was PTSD. The GAF was 55. In a June 2008 statement, the Veteran reported that he often could not sleep, or was too nervous to sleep, or something would startle him and cause him to awaken. At these times, he would begin to worry that someone was breaking into his car, his house or his mother's house and he could not return to sleep and would leave his home and walk around outside. In a June 2008 letter, the sheriff from the Veteran's town wrote that he had observed the Veteran wandering about the streets at various hours in a confused state. He also reported that the Veteran appeared to be unable to maintain employment. The Veteran was also afforded a VA examination in June 2010. His claims file was reviewed by the examiner. The Veteran reported symptoms of intrusive thoughts, sleep impairment, flashbacks, hyperarousal, irritability, agitation, and angry outbursts. He reported that he was no longer physically aggressive. He denied panic attacks, obsessive thoughts, ritualistic or compulsive behavior. He reported avoidant behavior of crowds and creeks, and stated that he was unable to be in a boat at night or before daylight, due to nervousness and because it reminded him of situations in Vietnam. The Veteran reported that he was able to enjoy his family and had a good relationship with his wife. Regarding his occupational history, the Veteran indicated that he was a fisherman/boat handler by trade. He reported that he was able to work on a boat when his father was alive, but only because his father was the boat handler/pilot. He ran the boat for 10 years after his father retired, but was not able to go out before dawn or at night and, therefore, he could not get many fishing jobs. The jobs he was able to get were because his father continued to help him with piloting. The Veteran also reported that prior to his cerebrovascular accident in 2003, he worked in construction for three years and then as a brick layer for an additional one and a half years, just prior to the stroke. The Veteran further reported that he had not worked since his stroke because his doctors placed him on medical restriction to avoid lifting. He also had been unable to work as a commercial fishing pilot because of his inability to pilot a boat before daylight. Currently, he only worked three months out of a year (and then only on weekends) with a game warden to tag shad, as he is able to pilot that boat during the day. He reported that no one else would hire him secondary to his limitations. On mental status examination, the Veteran displayed fair hygiene and was casually dressed. He appeared anxious. Speech was normal. Mood was slightly anxious and affect was full. His thoughts were linear and organized and he denied suicidal and homicidal thoughts. He also denied auditory and visual hallucinations. No delusional thought processes were noted. The Veteran was fully oriented, and demonstrated a capacity for sustained concentration, abstract thinking, and good judgment. His memory was slightly impaired. The diagnosis was PTSD, chronic, severe. The GAF score was 55. The examiner stated that there was no evidence of any mental disorder other than PTSD. The examiner further opined that the Veteran had significant anxiety in the context of his PTSD. He has been significantly impaired socially, as well as occupationally, as a result of the PTSD. The examiner noted that the Veteran was able to work as a commercial fisherman with his father because his father made exceptions for his limitations of being unable to pilot or charter a boat at night. However, the Veteran experienced occupational difficulty once he no longer had the option to work in the family business. He could not be hired as a commercial pilot because he was unable to charter the fishing boats prior to daylight, due to the severity of his anxiety as a result of PTSD. The examiner further opined that at this time, and in the past, the Veteran had been unable to sustain or maintain gainful employment due to the severity of his PTSD- specifically his inability to tolerate piloting the boats through creeks and piloting before daylight. Based on the evidence, and resolving all doubt in the Veteran's favor, the Board finds that his PTSD symptoms more nearly approximate the criteria for a 70 percent disability rating. In reaching this decision, the Board notes that the criteria for a 70 percent disability rating for PTSD are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. See Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). Deficiencies in the area of work have been documented throughout the appeal. The Veteran has reported that he is unable to work as a commercial fishing pilot because he is unable to pilot the fishing boats prior to daylight or at night (the general 'hours of operation' in this field), due to his PTSD symptoms. His testimony is credible. The June 2010 VA examiner has objectively confirmed that the Veteran is unable to work due to the severity of his PTSD. Deficiencies in terms of thinking have also been demonstrated, although the VA treatment records and examination reports show the Veteran's thought processes have generally been logical and linear throughout the appeal. In this respect, the Board notes that the Veteran's report of hypervigilance, specifically wandering the streets at night due to fear of his house and car being burglarized, shows some level of deficiency in his thinking. His testimony in this regard has been corroborated by the town sheriff. There is also evidence of deficiencies in the area of judgment and mood. VA treatment records show that his insight and judgment have varied between good and fair. Throughout the appeal, the VA treatment show the Veteran reported feeling angry, anxious, depressed, irritable, and short-tempered. This is evidence of a deficiency in his mood. In addition, there is some evidence of neglect of personal hygiene. At the November 2004 VA examination, the Veteran reported that his ability to maintain hygiene was fair, as long as he was reminded by his wife. Also, a June 2006 treatment note shows that he reported he must be told to change his clothes and to bathe. Additional VA records reveal that during many evaluations, the Veteran's grooming was observed as only fair. Accordingly, the criteria for a 70 percent disability rating are met. TDIU As explained in the Introduction, the issue of entitlement to a TDIU is part and parcel of the Veteran's rating claim as the evidence of record has reasonably raised the issue of entitlement to a TDIU. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2010). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2010). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2010). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of non-service connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). All Veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). In cases where the scheduler criteria are not met, an extraschedular rating is for consideration. 38 C.F.R. § 3.321. 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). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. The assignment of a rating evaluation is itself recognition of industrial impairment. In this decision, the Board has granted a 70 percent rating for PTSD. The Veteran is also service-connected for residuals of duodenal ulcer with symptoms of gastroesophageal reflux and esophageal diverticulum (rated 40 percent), tinnitus associated with hearing loss (rated 10 percent), and hearing loss (rated 0 percent). Accordingly, the percentage criteria for a TDIU under 38 C.F.R. § 4.16(a) are met. The question remaining then is whether the Veteran is precluded from obtaining or engaging in substantially gainful employment due to his service-connected disabilities. Based on the evidence of record, and resolving doubt in the Veteran's favor, the Board finds that he is precluded from obtaining or engaging in substantially gainful employment due to his service-connected PTSD alone. On a November 2007 application for TDIU benefits (that was denied by the RO in a December 2008 rating decision) the Veteran reported that he had worked as a seasonal self-employed commercial fisherman from 1970 to 2003. From 1997 to 2000, he worked for S. L. Bridge Builder driving a boat. He also reported that he worked for J.W. Construction from April 2001 to June 2003. He completed four years of high school and denied any formal technical training. In a November 2008 statement, the Veteran reported that he worked as a commercial fisherman, and specifically as a seasonal shrimper. He explained that typically the shrimp boats go out in the early a.m. and return in the late afternoon for a 12-hour day. He stated that he had not worked as a shrimper since 2003 due to his flashbacks and intrusive thoughts (he worked on a boat in Vietnam hauling troops upriver and usually at night). He reported that he is no longer able to go out at night and since it takes two hours to reach the ocean, no one will hire a person to run a boat that will only leave after daylight. He stated that during the prior off-seasons, he had worked at J. W. Construction laying brick because it was not as stressful as shrimping. In November 2008, the owner of J. W. Construction wrote that the Veteran had been employed there between December 2002 and October 2003 until he stopped due to his stroke. In a February 2011 letter, another former employer, J. W. (owner of U. B. S.) wrote that the Veteran was a shrimper who had worked for him in the off-season as a carpenter, mason, and concrete worker between 2001 and 2003, up until the day of his stroke. Based on the evidence of record, and resolving doubt in the Veteran's favor, the Board finds that he is unemployable due to his PTSD disability alone. Private medical records show that the Veteran suffered a stroke in June 2003. The Veteran reports that the stroke caused him to be unable to continue work in the field of construction during the shrimping off-season because his doctors placed him on medical restrictions against lifting. Credible lay evidence in the file shows that the Veteran has not worked since shortly after his stroke. The Veteran has been service-connected for PTSD since May 10, 2004. He has presented credible and competent lay testimony regarding the severity of his PTSD and its impact on his ability to work as a shrimper/commercial fisherman, which is his only occupation since his stroke. VA treatment records show that Veteran has had difficulties due to his PTSD. In addition, a VA examiner has opined that at this time, and in the past, the Veteran is unable to sustain or maintain gainful employment due to the severity of his PTSD. The VA examiner reviewed the claims file, included a synopsis of the Veteran's medical and social history, and performed an examination of the Veteran. A medical opinion that is a factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Based on the evidence, the Board resolves any doubt in the Veteran's favor to find that his service-connected PTSD renders him incapable of obtaining or retaining substantially gainful employment. ORDER A 70 percent disability rating for PTSD is granted, subject to the law and regulations governing payment of monetary benefits. Entitlement to a TDIU is granted, subject to the law and regulations governing payment of monetary benefits. REMAND The Veteran seeks service connection for interstitial lung disease, to include as secondary to asbestos exposure. Unfortunately, the claim must be remanded for further development. Although the Board regrets the additional delay, it is necessary to ensure due process and compliance with prior remand instructions. This case was remanded by the Board in October 2009 for additional development, which included a VA pulmonary examination with a medical opinion as to whether it is at least as likely as not that the Veteran has asbestosis or a pulmonary disorder due to service, including as a result of asbestos exposure. The Veteran was provided a VA examination in July 2010. A VA examiner diagnosed interstitial lung disease with no objective evidence of asbestos-related pulmonary disease. He did not, however, opine as to whether the diagnosed interstitial lung disease was etiologically related to military service. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (the Board errs as a matter of law when it fails to ensure compliance with its remand instructions.) Accordingly, the claim must be remanded for compliance with the Board's remand instructions to obtain the requested medical opinion with supporting rationale. Additionally, in the instant decision, the Board has granted an initial 70 percent disability rating for the Veteran's PTSD. The Veteran seeks entitlement to an disability rating in excess of 70 percent for this disability. This issue should be adjudicated on remand, following the receipt of any additional medical evidence, to include records from the Social Security Administration. The Board further notes that the United States Court of Appeals for Veterans Claims (Court) has recently noted that VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement special monthly compensation (SMC) under 38 U.S.C.A § 1114. See Bradley, 22 Vet. App. 280, 294 (2008) (finding that SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim"). Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. In the instant decision, the Board has granted entitlement to a TDIU based on the Veteran's service-connected PTSD alone. Although not rated as 100 percent disabling, for SMC purposes the condition satisfies the requirement of a "service-connected disability rated as total." See Buie v. Shinseki, 24 Vet. App. 242, 251 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008). In addition to the Veteran's PTSD, upon which the TDIU was granted, service connection is in effect for additional service-connected disabilities including: residuals of duodenal ulcer with symptoms of gastroesophageal reflux and esophageal diverticulum (rated 40 percent), tinnitus associated with hearing loss (rated 10 percent), and hearing loss (rated 0 percent), for a combined rating of 50 percent. In light of Buie and Bradley, and VA's obligation to maximize the Veteran's benefits, on remand, the RO must determine whether the Veteran is entitled to SMC benefits under 38 U.S.C.A § 1114(s). In doing so, the Board notes that a claim for service connection for interstitial lung disease is still pending and has been remanded for additional development in the instant decision. A grant of service connection for this disability could affect the Veteran's claim for SMC in this instance. As such, these issues are inextricably intertwined. Therefore, adjudication of the SMC claim must be deferred pending adjudication of the service connection claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are inextricably intertwined when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Finally, the Veteran has indicated that he is in receipt of Social Security Administration disability benefits. Records associated with the recent award have not yet been associated with the claims file. VA is obliged to attempt to obtain and consider those records. 38 U.S.C.A. § 5103A(c)(3); 38 C.F.R. § 3.159(c)(2); see also Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall contact the Veteran and ask that he identify any outstanding records pertaining to his disabilities dated since March 2010. After obtaining the necessary authorization forms from the Veteran, the RO/AMC must obtain any pertinent records and associate them with claims file. Any negative response shall be in writing and associated with the claims file. 2. The RO/AMC shall obtain from the Social Security Administration any additional records pertinent to the Veteran's claim for Social Security Administration disability benefits and any medical records concerning that claim. All efforts to obtain the records should be fully documented, a negative response should be requested if no records are available. 3. After associating any pertinent, outstanding records with the claims file, the RO/AMC shall return the claims file to the VA examiner that conducted the July 2010 VA pulmonary examination. If that examiner is not available, then the RO/AMC must make arrangements with an appropriate VA medical facility for a VA examination to ascertain the nature and etiology of the Veteran's interstitial lung disease. All pertinent symptomatology and findings should be reported in detail, and all appropriate studies should be performed. The examiner is asked to state whether it is at least as likely as that the Veteran's current pulmonary disorder (diagnosed as interstitial lung disease) had its onset in service; or, is causally related to service, to include alleged asbestos exposure. It is imperative that this question is addressed and supported with a rationale to avoid the claims file being returned for non-compliance/inadequate medical opinion. All findings, along with a fully articulated medical rationale for all opinions expressed, should be set forth in the examination report. In addition, the examiner must acknowledge and discuss lay evidence regarding any continuity of symptomatology since service. If the VA examiner determines that he or she is unable to provide the requested medical opinion without resorting to speculation, this shall be indicated in the report, along with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. The RO/AMC shall then adjudicate the Veteran's claims, including entitlement to a disability rating in excess of 70 percent for the PTSD. In light of the Court's decisions in Buie v. Shinseki, 24 Vet. App. 242, 251 (2011) and Bradley v. Peake, 22 Vet. App. 280, 293 (2008) that require VA to maximize a Veteran's benefits, and in light of the Board's award of a TDIU for service-connected PTSD alone, the RO must also now adjudicate the issue of entitlement to SMC based on a need for regular aid and attendance of another person, or on account of being housebound. 5. If any benefit sought remains denied the Veteran shall be issued a Supplemental Statement of the Case that addresses actions taken since the issuance of the last Supplemental Statement of the Case and given the opportunity to respond. Thereafter, if appropriate, the case is to be returned to the Board, following applicable appellate procedure. The Veteran need take no action until he is so informed. He has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this claim as a result of this action. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs