Citation Nr: 1303444 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 08-38 158 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for hypertension. 2. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). 3. Entitlement to an increased rating for plantar calluses, right foot, currently rated as noncompensable prior to September 2, 2009, and rated as 10 percent disabling effective September 2, 2009. 4. Entitlement to an increased rating for plantar calluses, left foot, currently rated as noncompensable prior to September 2, 2009, and rated as 10 percent disabling effective September 2, 2009. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to May 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in October 2006, a statement of the case was issued in October 2008, and a substantive appeal was received in December 2008. The United States Court of Appeals for Veterans Claims (the Court) indicated that the VA cannot unduly limit its consideration of claims for service connection for specific mental disorders under circumstances in which other diagnosed psychiatric disabilities may be present. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) [holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled]. In light of Clemons, and in view of the diagnosis of anxiety disorder, symptoms of PTSD, and symptoms of depression, PTSD, depression, the Board has expanded the issue to include any acquired psychiatric disability. The issue is as stated on the title page. The Board notes that the RO granted a total disability rating based on unemployability (TDIU) effective August 16, 2008. The RO granted a 100 percent schedular rating effective September 21, 2008. The Veteran's schedular rating was reduced to 90 percent on two occasions, before being restored to 100 percent effective February 18, 2010. When the Veteran's rating was reduced to 90 percent, the TDIU was restored. In short, either a 100 percent schedular rating or a TDIU rating has been in effect since August 16, 2008. The issue of entitlement to service connection for a psychiatric disability, to include PTSD, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In January 2001, the RO denied the Veteran's application to reopen a claim for service connection for hypertension. The Veteran failed to file a timely notice of disagreement. 2. Certain evidence received since the January 2001 decision is neither cumulative nor redundant of the evidence of record at the time of the January 2001 denial and, by itself or in conjunction with the evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim of service connection. 3. The Veteran's hypertension has been aggravated by his service connected diabetes mellitus type 2. 4. Prior to September 17, 2006, the Veteran's plantar calluses, right foot, were manifested by no more than a mild foot disability. 5. Effective September 17, 2006, the Veteran's plantar calluses, right foot, are manifested by a moderately severe foot disability 6. Prior to September 17, 2006, the Veteran's plantar calluses, left foot, were manifested by no more than a mild foot disability. 7. Effective September 17, 2006, the Veteran's plantar calluses, left foot, are manifested by a moderately severe foot disability CONCLUSIONS OF LAW 1. The January 2001 RO rating decision, which denied the Veteran's application to reopen a service connection claim for hypertension is final. 38 U.S.C.A. § 7105 (West 2002). 2. Evidence received since the January 2001 RO rating decision is new and material; accordingly, the claim for service connection for hypertension is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The Veteran's hypertension is secondary to his service connected diabetes mellitus type 2. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303, 3.310 (2012). 4. Prior to September 17, 2006, the criteria for entitlement to a compensable disability rating for the Veteran's service-connected plantar calluses, right foot had not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 5284 (2012). 5. Effective September 17, 2006, the criteria for entitlement to a disability evaluation of 20 percent, but no higher, for the Veteran's service-connected plantar calluses, right foot have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 5284 (2012). 6. Prior to September 17, 2006, the criteria for entitlement to a compensable disability rating for the Veteran's service-connected plantar calluses, left foot had not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 5284 (2012). 5. Effective September 17, 2006, the criteria for entitlement to a disability evaluation of 20 percent, but no higher, for the Veteran's service-connected plantar calluses, left foot have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by letters dated September 2005, April 2006, and June 2006. The United States Court of Appeals for Veterans Claims (Court), in Vazquez-Flores v. Peake, 22 Vet.App. 37 (2008) purported to clarify VA's notice obligations in increased rating claims. The Court held that a notice letter must inform the Veteran that, to substantiate a claim, he or she must provide, or ask VA 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. The Court also held that where the claimant is rated under a diagnostic code that 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, the notice letter must provide at least general notice of that requirement. The Board points out that the U.S. Court of Appeals for the Federal Circuit reversed the Court's holding in Vazquez, to the extent the Court imposed a requirement that VA notify a Veteran of alternative diagnostic codes or potential "daily life" evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Reviewing the September 2005, April 2006, June 2006, and October 2008 correspondences in light of the Federal Circuit's decision, the Board finds that the Veteran has received 38 U.S.C.A. § 5103(a)-compliant notice as to his increased rating claims. The notification complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court addressed directives consistent with VCAA with regard to new and material evidence. The Court stated that in order to successfully reopen a previously and finally disallowed claim, the law requires the presentation of a special type of evidence-evidence that is both new and material. The terms "new" and "material" have specific, technical meanings that are not commonly known to VA claimants. Because these requirements define particular types of evidence, when providing the notice required by the VCAA it is necessary, in most cases, for VA to inform claimants seeking to reopen a previously and finally disallowed claim of the unique character of evidence that must be presented. This notice obligation does not modify the requirement that VA must provide a claimant notice of what is required to substantiate each element of a service-connection claim. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In other words, VA must notify a claimant of the evidence and information that is necessary to reopen the claim and VA must notify the claimant of the evidence and information that is necessary to establish his entitlement to the underlying claim for the benefit sought by the claimant. In addition, VA's obligation to provide a claimant with notice of what constitutes new and material evidence to reopen a service connection claim may be affected by the evidence that was of record at the time that the prior claim was finally denied. In order to satisfy the legislative intent underlying the VCAA notice requirement to provide claimants with a meaningful opportunity to participate in the adjudication of their claims, the VCAA requires, in the context of a claim to reopen, the Secretary to look at the bases for the denial in the prior decision and to respond with a notice letter that describes what evidence would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. Therefore, the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied. In the present case, the Board observes that the RO furnished the appellant with an adequate notice letter in September 2005. It set forth the criteria for entitlement to the benefit sought by the appellant, and included discussion of new and material evidence so as to comply with the Kent requirements. The Board believes that the September 2005 notice constituted adequate notice to the appellant. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist VA has obtained service treatment records; assisted the appellant in obtaining evidence; afforded the Veteran physical examinations in October 2005, September 2009, and May 2010; obtained medical opinions as to the etiology and severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the appellant has not contended otherwise. New and Material Evidence The Board notes that despite the determination made by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001); see also VAOPGCPREC 05-92. Following notification of an initial review and adverse determination by the Regional Office (RO), a notice of disagreement must be filed within one year from the date of notification thereof; otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. Following receipt of a notice of a timely disagreement, the RO is to issue a statement of the case. 38 C.F.R. § 19.26. A substantive appeal must be filed within 60 days from the date that the agency of original jurisdiction mails the statement of the case to the appellant, or within the remainder of the 1-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 C.F.R. § 20.302(b). Otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. When a claim to reopen is presented, a two-step analysis is performed. The first step of which is a determination of whether the evidence presented or secured since the last final disallowance of the claim is "new and material." See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc); see also 38 U.S.C. § 5108; Hodge v. West, 155 F.3d 1356, 1359-60 (Fed. Cir. 1998). The provisions of 38 C.F.R. § 3.156 (which define "new and material evidence") provides as follows: New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012) Second, if VA determines that the evidence is new and material, the VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist has been fulfilled. See Winters v. West, 12 Vet. App. 203, 206 (1999) (en banc) (discussing the analysis set forth in Elkins), overruled on other grounds sub nom. Winters v. Gober, 219 F.3d 1375, 1378 (Fed. Cir. 2000); Elkins, supra. The second step becomes applicable only when the preceding step is satisfied. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 325 (1999). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). In Evans v. Brown, 9 Vet. App. 273 (1996), the Court held that to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the time that the claim was finally denied on any basis. Additionally, evidence considered to be new and material sufficient to reopen a claim should be evidence that tends to prove the merits of the claim that was the specified basis for the last final disallowance of the claim. In Justus v. Principi, 3 Vet. App. 510 (1992), the Court held that for new and material evidence purposes only, new evidence is presumed to be credible. The only exception would be where evidence presented is either (1) beyond the competence of the individual making the assertion or (2) inherently incredible. If new and material evidence has been received with respect to a claim that has become final, then the claim is reopened and decided on a de novo basis. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. The Veteran's claim for service connection for hypertension was denied by way of an October 1989 RO decision. The Board issued an April 1995 Decision in which it also denied the claim. Most recently, the RO issued October 1996 and January 2001 rating decisions in which it found that no new and material evidence had been received to reopen the claim. The Veteran failed to file a timely notice of disagreement. Consequently, the January 2001 rating decision became final. The evidence on record at the time of the January 2001 denial consisted of the service treatment records (which contained no findings attributed to hypertension), a July 1989 VA examination report that failed to include a diagnosis of hypertension, testimony from a September 1990 RO Hearing in which the Veteran testified that he has high blood pressure and takes medication for hypertension, statements from the Veteran that he was prescribed hypertension medication while in service, and private treatment reports reflecting treatment for hypertension. The basis for the denial was the fact that there are no findings in the service treatment records or within one year of service that were attributed to hypertension. There was also no medical opinion linking current hypertension to service. Evidence received since the January 2001 rating decision includes a new theory of entitlement that the Veteran's hypertension is secondary to his service-connected diabetes mellitus type 2. The Board notes that separate theories in support of a claim for a particular benefit are not equivalent to separate claims and a final denial on one theory is a final denial on all theories. As such, new and material evidence is necessary to reopen a claim for the same benefit asserted under a different theory. Velez v. Shinseki, 23 Vet. App. 199, 206 (2009). In this case, the Veteran has done more than simply offer a new theory of entitlement. He underwent a VA examination in May 2010 and the examiner opined that although hypertension was not caused by diabetes, it is a disability that has been worsened or increased by the diabetes. Consequently, the Veteran has submitted a competent medical opinion that substantiates his new theory of entitlement. The Board finds that this constitutes new and material evidence. Therefore, the claim is reopened. Service Connection The issue before the Board involves a claim of entitlement to service connection. Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet.App. 439 (1995). The Veteran has claimed that he was diagnosed with hypertension while he was in service. Specifically, he has stated that he was treated while in Europe (Germany) in 1971-1972. At his May 2008 RO Hearing, he testified that he was also treated for hypertension a couple of months after service. The Board notes that the service treatment records fail to reflect any findings attributed to hypertension. The Board acknowledges that the Veteran's blood pressure reading was 120/80 at his pre-induction examination (August 1965) and was 128/90 in November 1970. However, the Board notes that at the Veteran's separation examination (January 1973), his blood pressure was 110/64. The Veteran testified that he was treated by private physicians for hypertension a few months after service. However, records retrieved from those physicians (Drs. Hutchings, Williamson, Wilkerson, and Austin) are dated years after service. A May 1981 examination report reflects a blood pressure reading of 110/86. There was no diagnosis of hypertension. A July 1989 VA examination reflects blood pressure readings of 130/100 (sitting), 130/85 (recumbent), and 140/105 (standing). The Veteran was diagnosed with hypertension, systemic, labile. The Board finds that the there is no medical evidence that the Veteran had hypertension in service or within one year of service. Consequently, service connection cannot be granted on a presumptive basis. Moreover, since there is no competent medical opinion linking his current hypertension to service, the preponderance of the evidence weighs against service connection on a direct basis as well. However, the Board notes that with regards to whether the Veteran's hypertension was aggravated by his service connected diabetes mellitus type 2, the evidence weighs in favor of the Veteran's claim. As noted earlier, the Veteran underwent a VA examination in May 2010. After a thorough examination, the examiner noted that the Veteran's hypertension pre-dated his diabetes mellitus. As such, the examiner opined that the hypertension was not a complication of diabetes. However, he also opined that the Veteran's service connected diabetes aggravates his hypertension. The Board finds that service connection is warranted for hypertension and that compensation is payable for that degree of aggravation caused by the Veteran's service-connected diabetes mellitus. Allen v. Brown, 7 Vet.App. 439 (1995). Increased Ratings Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's service-connected plantar calluses have been rated by the RO under the provisions of Diagnostic Code 5284. Under this regulatory provision, a rating of 10 percent is warranted for a moderate foot injury. A 20 percent rating is warranted for a moderately severe foot injury. A 30 percent rating is warranted for a severe foot injury. The Veteran underwent a VA examination in October 2005. He complained of persistent pain with walking and a burning sensation. He reported that he has a flare-up of tinea pedis approximately five times per month, which he stated is not treated effectively with prescribed antifungal cream. He reported that he sits down to help with the itching and burning; and this impacts his activities of daily living in that it decreases the time that he is able to be active. The examiner noted that the Veteran walked with the help of a left handed cane. He did not wear corrective shoes or a brace. Upon examination, the Veteran's gait was without deficit. He had bilateral feet bunion deformity with hammertoes. He had a corn over the left distal interphalangeal joint of all the toes of the left foot excluded the great and overlying the right third toe, dorsal aspect. There was onychomycosis of the nails of the feet. There was interdigital tinea pedis. There was a callus site on the left heel and overlying the left medial first metatarsal, mild. There was pes planus deformity with no varus or valgus deformity of the ankle. Range of motion was dorsiflexion 20 degrees and plantar flexion 45 degrees. There was no instability to anterior drawer testing. The Veteran was diagnosed with: (1) bilateral bunion deformity with hammertoe deformity, (2) evidence of chronic tinea pedis inter digitally with onychomycosis of the nails, (3) corn of all toes of the left foot except the great and the right third toe, and (4) callus site of the left foot, lateral aspect of the heel and first metatarsal head, mild. The Board notes that prior to September 17, 2006, the Veteran had been diagnosed with multiple disabilities involving the feet and toes (bunions, tinea pedis, onychomycosis, corns, etc.). However, the only diagnosis that was service connected was the Veteran's calluses. The October 2005 VA examiner specifically stated that the callus site of the left foot was mild. He didn't even diagnose calluses of the right foot. Since a compensable rating is only warranted for a moderate foot injury, and the Veteran's service connected calluses were deemed no more than mild, the Board finds that a preponderance of the evidence is against a compensable rating prior to September 17, 2006. An outpatient VA treatment record dated September 17, 2006 reflects that the Veteran sought treatment for painful areas on the bottoms of his feet, and numbness in both feet, particularly around the great toe area. On examination, the Veteran had palpable dorsalis pedis and posterior tibial pulses bilateral. There was a left sub-fourth, severe sub-metatarsal head lesion that was painful to palpation in the left foot. There was bilateral first metatarsophalangeal joint hyperkeratosis. There was pain on palpation to all hyperkeratotic areas and the balls of the foot, as well as a left plantar central arch hyperkeratotic focal lesion that was painful. The examiner noted that the Veteran also seemed to have significant numbness in both feet. He diagnosed the Veteran with metatarsalgia with painful associated hyperkeratosis. The Veteran underwent another VA examination in September 2009. The examiner noted that he had treated the Veteran in November 2005, September 2006, and September 2007. He stated that the Veteran had chronic metatarsalgia due to his calluses. The Veteran rated the pain/discomfort of his foot calluses and tinea pedis as an 8 on a scale of 1-10. He complained of itching, burning, stiffness, redness, fatigability, and lack of endurance. He used a cane for ambulation; and he wore diabetic shoes. He also had shoe inserts to help with the calluses. He stated that he cannot exercise, walk, do yard work, and walk long distances. He stated that it is difficult to wear shoes for extended periods of time. He reported that he can stand for five to ten minutes, or walk for 1-1 1/2 blocks before significant pain ensues. Upon examination, the Veteran had palpable dorsalis pedis and posterior pulses bilateral. There was plantar medial first metatarsophalangeal joint and great toe hyperkeratosis bilaterally. There was left sub third metatarsal head hyperkeratosis that was painful to palpation. There was also first plantar medial first metatarsophalangeal joint hyperkeratoses which were painful to palpation. Each of the hyperkeratoses was moderately severe. The examiner diagnosed the Veteran with moderately severe hyperkeratosis with chronic metatarsalgia. He also diagnosed the Veteran with chronic interdigital tinea pedis, which was moderate in severity. Effective September 17, 2006, the medical treatment reports reflect bilateral first metatarsophalangeal joint hyperkeratosis, pain on palpation to all hyperkeratotic areas and the balls of the foot, and a left plantar central arch hyperkeratotic focal lesion that was painful. The September 2009 VA examiner (who also authored the September 17, 2006 treatment report) stated that the Veteran had "chronic metatarsalgia due to his calluses" and that hyperkeratosis was associated with the metatarsalgia. While the Veteran still has numerous diagnoses of the feet which do not appear to be related to service, the Veteran's metatarsalgia and hyperkeratosis are both apparently due to the Veteran's calluses. Consequently, the Veteran's rating is to be based on the severity of the calluses, but also of the metatarsalgia and hyperkeratosis. The September 2009 VA examiner explicitly diagnosed the Veteran with moderately severe hyperkeratosis with chronic metatarsalgia. Consequently, a rating of 20 percent appears to be warranted from at least this date. The severity of the Veteran's disability is more difficult to determine from September 17, 2006 to September 2, 2009 (the date of the VA examination). The September 17, 2006 treatment report does not explicitly state the severity of the foot disability. However, he did note that the Veteran has a severe sub-metatarsal head lesion that was painful to palpation in the left foot. In giving the benefit of the doubt to the Veteran, the Board finds that the Veteran is entitled to 20 percent ratings for service connected plantar calluses of the right and left feet. The Board notes that ratings in excess of 20 percent are only warranted for severe foot injuries. Although the Board noted that the examiner found the Veteran to have a severe sub-metatarsal head lesion on the left foot, there was no indication that this resulted in a severe disability to the entire foot. To the contrary, the examiner's subsequent September 2009 VA examiner explicitly stated that the severity of the Veteran's service connected foot disability was moderately severe. ORDER The claim for service connection for hypertension is reopened; and entitlement to service connection is warranted. To this extent, the appeal is granted. Prior to September 17, 2006, entitlement to increased ratings for plantar calluses of the right and left feet are not warranted. Effective September 17, 2006, ratings of 20 percent are warranted for the Veteran's plantar calluses of the right and left feet. To this extent, the appeal is granted. The above grants are subject to the laws and regulations governing payment of monetary awards. REMAND Psychiatric disability The Veteran claims that he suffers from PTSD as a result of stressors experienced in service. Initially, his claim was denied because his stressors were not verified. The RO subsequently recognized that the Board certain provisions of 38 C.F.R. § 3.304(f) (pertaining to claims for PTSD) were amended in 2010; and that the result is the elimination of the requirement for corroborating evidence of a claimed in-service stressor if it is related to the Veteran's "fear of hostile military or terrorist activity." The RO found, in its September 2012 supplemental statement of the case, that the Veteran's reported stressors were consistent with the places, types, and circumstances of service. Consequently, the RO scheduled the Veteran for a VA examination for the purpose of determining if the Veteran had a current diagnosis of PTSD and whether any such diagnosis was related to service. The Veteran underwent a VA examination in August 2012; and the examiner found that although the Veteran met some of the PTSD criteria, he did not meet Criterion E or Criterion F. The examiner determined that the Veteran does not have a current diagnosis of PTSD. However, he diagnosed the Veteran with an anxiety disorder (not otherwise specified) and an alcohol disorder (not otherwise specified). The Board also notes that the October 2006 outpatient treatment report (in which the Veteran was diagnosed with PTSD) also noted depressive symptoms. As noted in the introduction, the VA cannot unduly limit its consideration of claims for service connection for specific mental disorders under circumstances in which other diagnosed psychiatric disabilities may be present. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) [holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled]. Consequently, the Board finds that it cannot adequately decide the claim without competent medical opinion that addresses the etiology of each of the Veteran's psychiatric disabilities. The Board finds that the Veteran is entitled to another VA in-person psychiatric examination. For each psychiatric disability that is diagnosed, the examiner should opine whether it is at least as likely as not related to service, to include the Veteran's in-service stressors. Accordingly, the case is REMANDED for the following action: 1. The RO should make sure that the VA records are updated and in the claims folder. 2. A VA psychiatric examination should be scheduled for the purpose determining whether the Veteran's psychiatric disability or disabilities are at least as likely as not related to his military service. The examiner should be asked to review the claims file, examine the Veteran, and identify the specific stressor(s) underlying the diagnosis. The examiner should indicate whether "fear of hostile military activity" is a stressor that supports a diagnosis of PTSD. ("Fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device, incoming fire, including suspected sniper fire, and the Veteran's response to the event involved a psychological or psycho-physiological state of fear, helplessness, or horror. 75 Fed. Reg. 39852.) For each psychiatric disorder other than PTSD that is diagnosed (including, but not limited to, PTSD), the examiner should provide an opinion as to whether any such disorder is as least as likely as not related to the Veteran's military service (to include the Veteran's service related stressors). 3. After completion of the above, the AMC should review the expanded record and determine if the benefits sought can be granted. If the claim remains denied, then the AMC should furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record to the Board for further review. The appellant 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs