Citation Nr: 1315365 Decision Date: 05/09/13 Archive Date: 05/15/13 DOCKET NO. 09-00 863 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1986 to November 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In March 2008, the Board, in relevant part, denied the Veteran's claims for an increased rating in excess of 10 percent for supraventricular tachycardia and a compensable rating for chronic pelvic inflammatory disease with fibroids, and remanded the Veteran's claim for entitlement to a TDIU for issuance of a statement of the case. The Veteran appealed the March 2008 denial of increased ratings for supraventricular tachycardia and a compensable rating for chronic pelvic inflammatory disease with fibroids to the United States Court of Appeals for Veterans Claims (Court). In an October 2009 memorandum decision, the Court affirmed the Board's March 2008 denial of the Veteran's claims for increased ratings. The Veteran appealed that decision to the United States Court of Appeals for the Federal Circuit where the appeal was dismissed due to lack of jurisdiction. Thus, the issues of entitlement to increased ratings for the Veteran's service-connected supraventricular tachycardia and chronic pelvic inflammatory disease with fibroids is no longer before the Board for consideration. A review of the Veteran's Virtual VA electronic claims file shows that she subsequently submitted claims for entitlement to service connection for celiac disease, a claim to reopen a previously denied claim for entitlement to service connection for hypothyroidism, and an increased rating for supraventricular tachycardia. In a May 2012 rating decision, the RO granted and increased 30 percent evaluation for service-connected supraventricular tachycardia, effective May 31, 2012, and denied entitlement to service connection for celiac disease. A February 2013 letter indicates that a notice of disagreement pertaining to the May 2012 rating decision was received. In a January 2013 rating decision, the RO denied the Veteran's claim to reopen a previously denied claim of entitlement to service connection for hypothyroidism as it found that new and material evidence had not been submitted. There is no indication that a notice of disagreement has been received as to that issue. In conclusion, it appears that the Veteran currently has claims pending at the RO for an increased rating in excess of 30 percent for service-connected supraventricular tachycardia and for entitlement to service connection for celiac disease. Nevertheless, the issue currently on appeal, entitlement to a TDIU, was received and has been ongoing since January 2005. Given that the medical evidence of record appears to be complete with respect to the Veteran's claim for entitlement to a TDIU and for the sake of finality and judicial economy, the Board will proceed to a decision on the merits of the claim at this time. In November 2010, and August 2012, the Board remanded the Veteran's claim for entitlement to a TDIU for additional development. The case is now again before the Board for further appellate consideration. In July 2010, the Veteran testified at a Travel Board hearing before the undersigned Veteran's Law Judge. A copy of the hearing transcript is of record. In February 2013, an expedited processing request indicated that there is no additional information or evidence that had not been submitted for review. It indicated that if additional evidence is submitted in the future, the Veteran waived her right to have the case remanded to the Agency of Original Jurisdiction (AOJ) for review in the first instance. It was requested that the Board consider any new evidence and proceed with adjudication of this appeal. Thus, the Veteran's statement in support of her claim, received in April 2013, will be considered by the Board in adjudicating this appeal. See 38 C.F.R. § 20.1304 (2012). FINDINGS OF FACT 1. The Veteran's claim for entitlement to a TDIU was initially received on January 7, 2005. 2. The Veteran's service-connected disabilities include paroxysmal supraventricular tachycardia, rated as 10 percent disabling prior to February 6, 2012, and as 30 percent disabling thereafter; chronic pelvic inflammatory disease with fibroids, rated as noncompensably disabling (0 percent), and; status-post laproscopies, rated as rated as noncompensably disabling (0 percent). 3. Throughout the course of this appeal, for the purposes of 38 C.F.R. § 4.16(a), the Veteran's combined disability rating has not exceeded 40 percent at any time. 4. The evidence of record does not show that the Veteran's service-connected disabilities, in and of themselves, render her unable to secure or follow a substantially gainful occupation. CONCLUSION OF LAW The criteria for entitlement to TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.16, 4.18, 4.19, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION As noted above, the Board remanded this matter March 2008, November 2010, and August 2012 for additional development. In March 2008, the Board remanded the claim for issuance of a statement of the case, which was issued in November 2008. In November 2010, the Board again remanded that claim on appeal for obtainment of a VA examination to determine whether the Veteran's service-connected disabilities render her unemployable, and readjudication of the claim. The Veteran was afforded a VA examination in December 2010 and the claim was readjudicated in the January 2012 supplemental statement of the case. In August 2012, the Board again remanded the claim on appeal for obtainment of all available VA treatment records and examination reports, to include a May 2012 VA examination report that had not been associated with the paper or electronic claims files, obtainment of a contemporaneous VA examination of the Veteran's service-connected disabilities, and reajudication of the claim. In October and December 2012, VA treatment records and examination reports dating through October 2012, to include the May 2012 examination report, were associated with the Veteran's Virtual VA electronic claims file. In October 2012, the Veteran was afforded an additional VA examination and the case was reajudicated in a February 2013 supplemental statement of the case. Thus, there is substantial compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). VA's Duty to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a pre-rating letter mailed to the Veteran in February 2005, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate her claim for a TDIU, as well as what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. In a subsequent post-rating letter dated in March 2006, the Veteran was provided notice regarding VA's assignment of disability ratings and effective dates as required under Dingess/Hartman. VA's failure to provide such notice prior to the June 2005 rating decision, however, has not been shown to be prejudicial to the Veteran in this case. Specifically, since the Board herein denies the Veteran's claim for entitlement to a TDIU, neither a disability rating nor an effective date for any assigned disability rating is to be assigned. Accordingly, there is no possibility of prejudice to the Veteran arising out of VA's failure to provide notice as to the assignment of disability ratings and effective dates prior to the June 2005 rating decision. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate her claim. The Veteran's service treatment records, claims submissions, VA treatment records, employment information, and lay statements and testimony have been associated with the record. The Veteran was also afforded VA examinations in December 2010 and May and October 2012 to examine the severity of one or more of her service-connected disabilities and associated effects of those disabilities on her occupational and daily functioning. These examinations and opinions, along with the other evidence of record, are fully adequate for the purposes of determining whether the Veteran's service-connected paroxysmal supraventricular tachycardia, chronic pelvic inflammatory disease with fibroids, and status-post laparoscopic surgery disabilities have rendered her unable to secure and follow a substantially gainful occupation. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board also observes that the Veteran was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which she presented oral argument in support of her TDIU claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2011) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issue on appeal during the hearing. Significantly, neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran and her representative, through their testimony, demonstrated that they had actual knowledge of the elements necessary to substantiate her claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. TDIU Under VA laws and regulations, a TDIU may be assigned upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In this case, as noted above, service connection is in effect for paroxysmal supraventricular tachycardia, rated as 10 percent disabling prior to February 6, 2012, and as 30 percent disabling thereafter; chronic pelvic inflammatory disease with fibroids, rated as noncompensably disabling (0 percent), and; status-post laparoscopies, rated as noncompensably disabling (0 percent). The Veteran's assigned combined disability rating is 10 percent prior to February 6, 2012, and 30 percent thereafter. Consideration may be given to a veteran's level of education, special training, and previous work experience, but age and the impairment caused by non-service-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned even where the combined rating for the veteran's service-connected disabilities is less than total if the disabled veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purpose of determining the above, the following will be considered as one disability: 1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor set forth under 38 C.F.R. § 4.26, if applicable; 2) disabilities resulting from common etiology or a single accident; 3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; 4) multiple injuries incurred in action; or 5) multiple disabilities incurred as a prisoner of war. In exceptional cases, an extra-schedular rating may be assigned on the basis of a showing of unemployability alone. See 38 C.F.R. § 4.16(b). Such cases are referred to the Director of the Compensation and Pension Service for extra-schedular consideration. At no time during the course of this appeal have the disability ratings assigned for the Veteran's service-connected disabilities resulted in a combined disability rating that meets the regulatory requirements for a schedular TDIU under 38 C.F.R. § 4.16(a). The Veteran's combined disability rating prior to February 6, 2012, was 10 percent. Since February 6, 2012, her combined disability rating is 30 percent. Her only compensable disability rating since her January 2005 claim for entitlement to a TDIU was received, is for paroxysmal supraventricular tachycardia. Her service-connected pelvic inflammatory disease with fibroids and status post laparoscopic surgery have both been evaluated as noncompensable throughout the duration of the claim for entitlement to a TDIU. Thus, as acknowledged by the Veteran and her representative during the July 2010 Travel Board hearing, the Veteran's appeal turns upon the question of whether the extent of her service-connected disabilities are so exceptional as to warrant consideration of a TDIU on an extra-schedular basis under 38 C.F.R. § 4.16(b). The Veteran's claim for entitlement to a TDIU was received on January 7, 2005. In support of her claim for a TDIU, the Veteran has asserted through her claim submission, various written statements, and her July 2010 Board hearing that either solely her service-connected heart disability, and/or her service-connected heart disability in connection with her service-connected chronic pelvic inflammatory disease with fibroids and status post laparoscopic surgeries have rendered her unable to obtain and maintain substantially gainful employment since 2002. In her January 2005 claim, the Veteran asserted that her service-connected tachycardia disability results in fatigue, which prevents her from securing or following any substantially gainful occupation. She indicated that her heart disability affected her employment in 1996, which is when she was last employed as a full-time building manager doing field and office work for the Federal Government General Services Administration (GSA). She was employed at that agency from 1991 to 1996, with 7 months time lost due to illness. One reason why she left employment at the GSA was incompatibility with her worsening health issues. She reportedly became too disabled to work in 2002. She reported 6 years of college level education, military training, and facilities management training from 1992 to 1993. In a January 2005 statement, the Veteran reported symptoms of extreme fatigue and a wildly fluctuating heart rate, which is frequently 90+ beats per minute. She reported heart arrhythmias more than four times a day on most days. She indicated that her fibroids cause pelvic pain for which she has had to take at least 800 mg of ibuprofen for relief. Similar symptom manifestations of the Veteran's service-connected disabilities were again reported by her in an August 2005 statement. She indicated that her paroxysmal supraventricular tachycardia was manifested by symptoms of heart pain, dizzy spells, and significantly increased frequency of sinus arrhythmias with episodes of sinus tachycardia and extreme fatigue. She reportedly experienced such symptoms with sinus arrhythmias and episodes of sinus tachycardia several times daily. Despite taking prescribed beta blocker medication for control of her heart rate, it was not uncommon for her heart rate to be in the range of 90 beats per minute with fluctuations, thus, her heart condition is not controlled with use of medication. Moreover, beta blocker medication did not control or relieve her heart palpitations. She claimed that VA must compensate her for the loss of her quality of life as her service-connected heart condition will lead to her need for a pacemaker at best or heart failure at worst. She claimed that she is unemployable due to discomfort, exhaustion, and general ill feelings associated with her service-connected heart disability and "this disease process." As to her service-connected chronic pelvic inflammatory disease with fibroids, she reported symptoms of heavy bleeding and extreme pain. In July 2008, the Veteran submitted an extremely detailed, medically intricate, and well written statement that is 16 single-spaced pages in length, accompanied by intermittent treatment records, laboratory reports, and documentation and analysis of her own electronic research of medical literature. Her reported cardiac symptoms included shortness of breath, fatigue, dizziness, palpitations, and chest pain. She described her palpitations as aggravating and stated that they robbed her of oxygen and resulted in shortness of breath, which made her days difficult. She stated that some arrhythmias included sinus tachycardia, junction escapes, sinus pauses, premature atrial contractions, high grade second degree AV block with dropped beats, and a first degree 2:1 AV block followed by a dropped complex, late beats, and dropped beats. She stated that Holter monitoring showed some arrhythmias that "were definitely of the pace maker variety." She stated that in addition to paroxysmal sinus ventricular tachycardia, she experiences additional types of arrhythmias that always trouble her to some degree and further contribute to her diminished quality of life. She stated that while symptom manifestations of her heart condition had been described, the underlying disease process had not been diagnosed. She opined that possible diagnoses included dilated cardiomypoathy and sick sinus syndrome, among others. She claimed that a slight rise and return to normal in her AST level in mid 2005 was indicative of a heart attack. Treatment for her heart condition included beta blocker medication which helped control her heart rate but provided no relief as to her "many different heart arrhythmias." She indicated that Holter and event monitoring of her heart is problematic because arrhythmias occur spontaneously without regard to her activity level. She stated that as to any conclusion or suggestion that her cardiac symptoms do not interfere with her normal activities is inconsistent with the medical evidence of record, her medical discharge from service due to a heart condition, and her unemployment since 1997 due to heart problems. She indicated that her only daily activity is using a computer to attempt to find out what is medically going on with her. As to her service-connected pelvic disabilities, in her July 2008 statement, the Veteran indicated that she has had significant pelvic pain. Treatment included past laparoscopic surgeries to remove adhesions. Current treatment included 800mg ibuprofen. She also reported a history of ovarian cysts that resulted in irregular menstrual bleeding and severe pain. She reportedly experienced pelvic pain 2 to 3 weeks a month. She stated that her uterine fibroids have resulted in her loss of enjoyment and inability to participate in life and she claimed that they may result in infertility. As to her employability, the Veteran's July 2008 statement indicated that it should be obvious that she is unemployable due to numerous medical and psychiatric conditions, to include her service-connected heart and pelvic disabilities. She attributed her unemployability to partial diagnosis, delayed diagnosis, and failure to diagnose her medical conditions by both in-service military and post-service VA medical personnel. She reiterated that her "disease process" includes chronic fatigue issues, hushimoto thyroiditis, hypothyroidism, celiac disease, heart arrhythmias, chest pain, joint pain, and depression among others. She included detailed explanations as to how each disability, and the combination of service and non service-connected disabilities result in her inability to obtain and maintain a substantially gainful occupation regardless of activity level of the occupation. She indicated that her chronic fatigue results in extensive exhaustion on a daily basis that makes it impossible to get up and perform employment in a satisfactory manner. Daily heart palpitations and heart pain on most days leave her breathless, dizzy, and result in general feelings of exhaustion. Such problems reportedly remain unresponsive to treatment with medication. Even the smallest of stressful events ensured more cardiac activity for that particular day while better days only offered slightly less cardiac activity. She stated that largely due to her own efforts and persistence, her VA medical providers are now on the right track which makes some improvement in her medical condition possible, however, significant improvement is not probable once all potential endocrine problems that are "likely to exist but remain undiscovered," and developing autoimmune responses are considered. She stated that once her cardiac and psychological hurdles are added, VA should be able to concede that she is truly unemployable. The Veteran's July 2008 statement also described the circumstances surrounding her unemployment since late 1996 or 1997. She explained that she took a leave of absence from employment at GSA from April to October 1996 to attend to her health, "which was failing." On return in October 1996, she received a "fake buyout" issued by "someone in her organization." She believed that she was being targeted. Because she was too sick to continue going on, the incident worked out in her best interest. During the July 2010 Travel Board hearing, the Veteran's representative testified that he and the Veteran are aware that she does not meet the schedular percentage requirements for entitlement to a TDIU. The Veteran testified that her claims for service connection for hypocholesterolemia and hypothyroid conditions and for increased ratings for pelvic inflammatory disease and supraventricular tachycardia were on appeal at the United States Court of Appeals for Veterans Claims, thus, a final decision as to those issues had not been made. She reported cardiac symptoms of increasing palpitations, fatigue, and chest pain. She experienced different types of palpitations all day every day that are fatiguing and disruptive of her daily activities. Regardless of physical activity or exertion, he heart will "jump off on a bad heart beat" without warning. Also, her heart rate fluctuates anywhere from 70 to 100 beats per minute in an instant, without warning, all day every day. Episodes lasted from 5 to 20 minutes during which she feels like she is running out of breath and becomes exhausted due to feelings of breathlessness and fatigue. Treatment included beta blocker medication since a number of years prior, however, neither medication nor anything else controlled the frequency of episodes of palpitations. During episodes she must sit still, breathe, and wait 15 to 20 minutes until it passes, which she must do multiple times a day. She could not control how long between episodes or the duration of each episode of palpitations. She had received emergency treatment for palpitations. As to her educational and occupational background, the Veteran testified that following her discharge from service in November 1990, she completed her undergraduate degree in business and obtained a masters degree and public administration. She worked in a managerial position at the GSA from 1990 until she resigned in 1996 when she felt that her disability had resulted in her inability to effectively discharge her occupational duties. She had been unable to seek employment since due to fatigue and lack of focus, work effectiveness, and an inability to work to the best of her ability. While she had filed for Social Security disability benefits, she vaguely indicated that "something was delayed" and she was directed to re-file. She had not refilled her claim or undergone any evaluations in connection with a claim for Social Security disability benefits. Additionally, the only treatment records submitted to the SSA were VA treatment records. The Veteran's representative indicated that she experiences anxiety associated with her service-connected heart and pelvic disabilities. He suggested that a psychiatric examination may be warranted as anxiety associated with service-connected disabilities prevents her from seeking employment. Specifically, she feared that she will not succeed in employment due to episodes of palpitations on the job and due to any need to take time off for treatment of her illness. The undersigned explained, however, that that the only issue that the Board has jurisdiction to consider is entitlement to a TDIU due to service-connected disabilities. On questioning by the undersigned, the Veteran indicated that she intended to file a claim for service connection for a psychiatric disorder associated with her medical condition. Her representative stated that the Veteran understood that such claim may affect the issue of entitlement to a TDIU. The undersigned explained that the Board does not have jurisdiction to address or consider a claim for service connection for an acquired psychiatric disorder; however, if the Veteran wished to file a claim for such, she may do so at the RO. To date, there is no indication that a claim for service connection for a psychiatric condition secondary to service-connected disabilities has been received. Turning to the medical evidence of record, on VA examination in December 2004, it was noted that historically, the Veteran's complaints of pelvic pain began in 1988. At that time, pelvic adhesions and fluid were seen on ultrasound examination. She was diagnosed with pelvic inflammatory disease, which was treated with antibiotics. Pelvic pain continued thereafter and laparoscopic surgery was performed in 1988 for removal of pelvic adhesions. During examination in December 2004, the Veteran denied any further episodes of pelvic pain. The examiner noted a current diagnosis of fibroids as they were seen on a recent transvaginal ultrasound. As to the Veteran's heart disability, historically, palpitations accompanied by shortness of breath began during service at age 19. The Veteran had been diagnosed with mitral valve prolapse and paroxysmal supraventricular tachycardia. Continued cardiac symptoms included occasional palpitations and shortness of breath, which occurred approximately 5 or 6 times a day and lasted from seconds to five minutes. There were no precipitants or alleviants of symptoms and exercise did not change her symptoms. Treatment included use of one beta blocker medication. Prior work-up of her heart condition included a chest x-ray in August 2004, which was read as negative. Also, in October 2004, a myocardial perfusion study was performed with exercise, which was read as normal with notation that perfusion abnormalities documented during a June 2004 study were not detected. A METs level of 10.1 was reached with a double product of 21, 924. Resting EKG was normal with normal sinus rhythm. Left ejection fraction was 70 percent. There was no evidence of ischemia or infarct and it was otherwise thought to be negative. The December 2004 VA examiner diagnosed history of pelvic inflammatory disease, currently without symptoms, and paroxysmal supraventricular tachycardia treated with Atenolol. In an August 2005 Compensation and Pension note, the Veteran's VA cardiologist indicated that event monitoring of the Veteran's heart in December 2004 showed sinus rhythm with periods of sinus tachycardia with arrhythmias, which were physiologic in nature. There were periods of sinus tachycardia when heart rate had gone up to 137 beats per minute but no extra beats were noted. Another entry showed sinus arrhythmias (heart rate goes up and down with breathing), which were physiologic with extra atrial beats and some extra atrial beats appeared to be artifact. Another entry showed sinus tachycardia (rapid heart rate), sinus arrhythmias and no extra beats. Another entry showed sinus tachycardia heart rate of 104, some abnormal atrial rhythm coming from a different atrial focus instead of sinus node, and some extra atrial beats which were non conducted and abnormal. A final entry showed normal sinus rhythm with extra atrial beats. The cardiologist noted that the Veteran complained f symptoms during some of the entries and dates. A November 2005 cardiology treatment note shows that historically, the Veteran was told to have mitral valve prolapse when she was being followed by a different VA Medical Center. Evaluation with repeat stress test was normal and she was evaluated by an invasive cardiologist but was not considered to be a candidate for cardiac catheter. Repeat event monitoring in December 2005 showed only sinus tachycardia with premature atrial contraction. Complaints included vague aching in the chest, joint pains, and fatigue. Diagnoses included atypical chest pain, history of mitral valve prolapse, and tachycardia. It was noted that a past documented history of mitral valve prolapse could have been intermittent. Except as otherwise noted, VA treatment records and examination reports dating through 2012 are reflective of the same diagnoses and complaints. In November 2007, the Veteran presented with paperwork requesting a description of her ability to do physical work related activities and mental related activities. Her primary care provider stated that the Veteran is currently unable to work due to chronic fatigues issues, mitral valve prolapse, tachycardia, hypothyroidism, hypercholesterolemia, osteoarthritis, etc. This information was reiterated by the Veteran's primary care physician in a March 2008 statement when it was also noted that she was undergoing work-up for epigastric pain. From December to January 2009, repeat Holter monitor testing was performed. An April 2009 cardiology note indicates that repeat event monitoring showed only normal sinus rhythm. The Veteran continued to report vague aching pains in the chest and joint pains. She also reported constant fatigue and tiredness. Diagnosis was atypical chest pain, hypothyroidism, history of mitral valve prolapse which may have been intermittent as no mitral valve prolapse had been seen in most recent echocardiogram, tachycardia, and hypercholesterolemia. In October 2009 the Veteran's VA primary care physician entered an endocrinology consultation request, which indicated that the Veteran presents with a constellation of symptoms described each time she comes in for evaluation. She had undergone extensive evaluations in the last year for multiple concerns: polycystic ovaries, elevated testosterone levels, celiac sprue, etc. A new concern of a vitamin D deficiency was noted but the Veteran felt that VA did not know enough about this to treat her. It was noted that all evaluation measures had been exhausted in primary care and that she would more likely agree to evaluation and treatment from a subspecialist than from primary care. In October 2009, the Veteran's VA primary care physician requested an occupational therapy evaluation and treatment for hip pain. A constellation of symptoms was again noted with request for evaluation and it was noted that this is a socially complicated satiation. In December 2010, the Veteran underwent a VA general medical examination. The medical record was reviewed. The examiner noted a diagnosis of paroxysmal supraventricular tachycardia. The Veteran indicated that she still has intermittent issues with orthostatic hypotension, which at one point had been labeled paroxysmal supraventricular tachycardia. She stated that this contributes to her fatigue, which makes sustaining employment difficult. The course since onset had been intermittent with remissions and current and past treatment included beta blocker medication with fair response and no side effects. A review of symptoms was positive for fever, chills, history of malaise, fatigability, generalized weakness, cold intolerance, palpitations, hoarseness. There was no cardiac history of myocardial infarction. Continuous medication was required for heart disease. Pulmonary history was positive for dyspnea on exertion. Pulmonary examination was negative for evidence abnormal breath sounds. Cardiac examination was negative for evidence of congestive heart failure and pulmonary hypertension. S1 and S2 heart sounds were present and a 2/6 SEM murmur was noted. Rhythm was regular. Heart size was normal. Lab tests were completed and reviewed, Chest x-ray was read as negative. Echocardiogram/Holter/Echo was performed and revealed normal sinus rhythm at 74 beats per minute. Echocardiogram was normal. The December 2010 examiner also noted diagnosis of chronic pelvic inflammatory disease with fibroids. Associated symptoms reported included irregular and excessive menstrual bleeding, which had become progressively worse since onset. She was not receiving any current treatment, however, past treatment included two laparoscopic procedures in 1988 for pelvic issues and adhesions. The Veteran reported interference with employability related to ongoing pelvic pathology and not the laparoscopic procedures. Course since onset had been stable. A review of gynecologic symptoms was positive for history of a positive pregnancy test and spontaneous abortion during service, pelvic pain, abdominal pain, abnormal vaginal bleeding, and right greater than left ovarian pain. There was no history of surgery or hospitalization since the most recent VA examination in 2004. Physical inspection of the abdomen was normal. There were no palpable masses, hernias, ascites, guarding of the abdomen or tenderness. Gynecological physical examination was deferred and not performed. Review of a September 2009 transvaginal and transabdominal ultrasound due to clinical history of an ovarian cyst and enlarged endometrium revealed irregular uterus contour and borderline size. Multiple fibroids were identified. The largest was seen posteriorly and measured 4.3x3.5x3.4 cm. Additional fibroids were seen in the anterior wall and in the right wall. There were no abnormalities of either ovary and there was no free fluid seen in the cul-de-sac. Following physical examination of the Veteran, a review of the claims file, and the Veteran's reports during examination, the December 2010 examiner diagnosed paroxysmal supraventricular tachycardia, current clinically asymptomatic, and; chronic pelvic inflammatory disease with fibroids. Paroxysmal supraventricular tachycardia affected the Veteran's usual occupation and resulted in a work problem of fatigue. It affected her usual daily activities in that when symptomatic, she noted problems with all activities of daily living. There was slight limitation of physical activity due to the Veteran's diagnosed heart abnormality. There were no symptoms at rest but ordinary (moderate) physical activity resulted in cardiac symptoms such as fatigue, dyspnea, etc. The Veteran's diagnosed chronic pelvic inflammatory disease with fibroids resulted in work problems and occupational activities due to pain and abnormal bleeding. There were no effects on her usual daily activities. The Veteran's usual occupation was a property manager for the GSA, however, she had been unemployed but not retired since 10 to 20 years prior, reportedly due to fatigue, a heart condition, and pelvic pain. The examiner opined that the Veteran's intermittent problems with fatigue and abnormal menstrual cycles would make it difficult for her to sustain gainful employment in a heavy labor type of employment. However, he felt that she is medically able to complete tasks required with a sedentary type of employment and her [service-connected] conditions do not make this an impossibility. In May 2012, the Veteran underwent a VA heart conditions examination. It was noted that she was diagnosed with supraventricular arrhythmia during military service in 1990 after experiencing palpitations and shortness of breath. Since then, she felt worse with more shortness of breath and fatigue. Continuous medication was not required for control of her heart condition. She experienced more than four episodes of supraventricular tachycardia cardiac arrhythmias in the last 12 months. She had not had any non-surgical or surgical procedures for treatment of a heart condition and there were no other hospitalizations for treatment of a heart condition. On physical examination, the Veteran's heart rate was 91 and rhythm was regular. The point of maximal impact was not palpable. Heart sounds were normal. There was no jugular venous distension. Her lungs were clear to auscultation. Peripheral pulses were normal in the bilateral lower extremities and her blood pressure was 100/68. An EKG was performed and read as normal. Chest x-ray in December 2010 was read as normal. An interview-based METs test was performed. Symptoms during activity included dyspnea and fatigue. The lowest activity level that the Veteran reported symptoms was greater than seven to ten METs, which level is consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging at 6 miles per hour. There were no other non-cardiac medical conditions limiting the Veteran's METs level. The Veteran's heart condition impacted her ability to work in that she gets shortness of breath upon moderate exertion. The Veteran was afforded an additional VA examination of her service-connected supraventricular tachycardia arrhythmia in October 2012. An addendum shows that the claims file was reviewed in conjunction with the examination. The examiner noted a history of a fast heart rate and palpitations. She had been seen by cardiology without cardiac diagnosis except for paroxysmal tachycardia, which was intermittent in frequency. Episodes of tachycardia had been documented on EKG and Holter monitor. She had been prescribed atenolol for her heart condition in the past, but stopped taking it. Thus, continuous medication was not required for control of the heart condition. She had not had any non-surgical or surgical procedures for treatment of her heart condition. She had been hospitalized at a VA facility for treatment of tachycardia. On physical examination her heart rate was 101. The point of maximal impact was the 4th intercostals space. Heart sounds were normal. There was no jugular venous distension. Her lungs were clear to auscultation and peripheral pulses were normal. There was no edema of the lower extremities. Her blood pressure was 108/72. Recent EKG testing in May 2012 was normal. An interview-based METs test conducted during examination indicated that the Veteran experienced dyspnea at greater than seven to ten METs, which level has been found to be consistent with actives such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging (6 miles per hour). The examiner stated that the Veteran's METs level limitation is not solely due to her heart condition and opined that only 20 percent of her METs level limitation is due solely to her heart condition. Following interview and examination of the Veteran, the Veteran's reports during examination, and review of the claims file, the May 2012 examiner opined that the Veteran's heart condition does not impact her ability to work. It was noted that the Veteran was most recently employed as a facilities manager for the federal government for five years. She stopped working in 1996 due to health issues. Educationally, she obtained a bachelors degree in business, and a masters degree in public administration. The Veteran described herself as bedridden a lot, however, the examiner found no reason why the Veteran cannot be employed. The examiner stated that the Veteran experiences episodes of supraventricular arrhythmias and she is not on any medication for arrhythmias. The examiner stated that she is highly educated and capable of taking care of herself, thus, she should be able to do any job that does not require manual labor. In an April 2013 statement, the Veteran alleged that VA adjudicators had not read the information and evidence that she has submitted in support of her claim. She stated that the October 2012 VA examination report should have indicated that she experiences intermittent paroxysmal supraventricular tachycardia or at least some form of tachycardia daily. She stated that her pulse (101 beats per minute) on the date of the October 2012 examination was "tachy" as anything above 72 beats per minute is considered fast. She stated that the examiner cannot state what effects her heart condition has on her occupational functioning because she was not doing any work for the examiner, nor could she. She stated that heart palpitations are not normal and the examiner is wrong as examination could not have been normal. She stated that the activity level of any prospective employment is irrelevant because her symptoms are not associated with activity level or physical exertion. Her symptoms are psychologically distressing so even sedentary employment is not an option as nothing would get done because she does not feel well, thus, she is unemployable. She stated that she will not seek employment until her heart palpitations stop and VA prescribed medication has been unsuccessful which is why she is no longer taking medication as it has not provided relief. She indicated that she had not sought treatment because the treatment and medication provided by VA has failed to resolve her heart condition and not because she has not been experiencing symptoms. As to her service-connected pelvic condition, she indicated that the examiner did not check the fact that her symptoms are not controlled with medication and she has had and continues to have problems with fibroids as evidenced by findings of new and growing uterine fibroids. She stated that adjudicators have failed to mention that the fact that fibroids have caused her to delay or deny childbirth is also compensable. She stated that she has slowly had to go through her medical records in between heart palpitations and fibroid pains to respond to VA's requests for additional information and evidence and she requested that the adjudicator actually read her submissions. Overall, the medical evidence shows that, for all periods relevant to this appeal, the Veteran's service-connected paroxysmal supraventricular tachycardia has been manifested by atypical chest pain, history of mitral valve prolapse, tachycardia, palpitations, fatigue, and shortness of breath regardless of her activity level. Additionally, her service-connected chronic pelvic inflammatory disease with fibroids and status post laparoscopies has been manifested by abdominal pain and irregular menstrual bleeding. Despite these manifestations, the Veteran has been frequently documented in VA treatment records as stating that she has no problems taking care of herself, which would appear to indicate that she retains good overall functional ability. See October 2007, October 2008, March 2010 VA primary care notes. Regarding her occupational and educational experience, the Veteran has reported an educational background with a bachelor's degree in business and a master's degree in public administration. Her reported training includes military training as a medic and building facilities training in the 1990s. Following service, she completed her education and worked as a building facilities manager for the GSA until 1996 or 1997. As noted above, since being unemployed, the Veteran spends her days researching medical conditions that she believes may be indicated by her physical symptoms and complaints. Her numerous detailed statements are evidence of this and she explicitly stated this in her July 2008 statement. Certainly the Veteran's service-connected heart and pelvic disabilities have adverse affects on her occupational functioning as described by her in her statements and testimony of record and as noted in the aforementioned VA examination reports. Specifically, VA examiners have repeatedly found that her service-connected heart and pelvic disabilities result in an inability to perform physically demanding occupational tasks or manual labor. Information obtained from the Veteran's previous employer, the GSA, indicates that she took a medical leave of absence due to an unstated medical condition. In this regard, the Board notes that VA treatment records show that the Veteran underwent breast augmentation surgery in 1996. See April 19, 2007 VA Women's Clinic Note. The Veteran has indicated that she took a leave of absence to have her service-connected heart condition examined. In November 1996, the Veteran signed a document for consideration of her intent to take advantage of an opportunity to separate with a voluntary separation incentive payment of not greater than $25,000 from the GSA. The Veteran has not submitted any objective medical evidence showing that her voluntary resignation from employment in 1996 or 1997 was solely due to manifestations of her service-connected paroxysmal supraventricular tachycardia, chronic pelvic inflammatory disease with fibroids, and status post laparoscopic surgeries. Indeed, VA treatment records, to include the aforementioned November 2007 and March 2008 statements from her VA primary care physician pertaining to employability, show treatment for multiple medical and psychiatric conditions. In fact, the November 2007 and March 2008 statements of her primary care physician pertaining to her employability opine that she is unemployable due to additional non service-connected disabilities of hyperthyroidism, hypercholesterolemia, and osteoarthritis. The Board also notes that a December 2006 treatment note indicates that she was nervous and felt uncomfortable driving related to her involvement in a past motor vehicle accident. As acknowledged in the aforementioned VA examination reports, her service-connected heart and pelvic disabilities prevent her from engaging in a physical demanding occupation and manual labor. Nonetheless, the examiners determined that the Veteran remains capable of performing work associated with sedentary employment which is consistent with the Veteran's educational background and occupational history. Indeed, given the functional capacity with the ability to care for herself, her continued independence with activities of daily living demonstrated by the Veteran throughout the course of this appeal, accompanied by her research and analysis of complicated and intricate medical literature, the Board finds that the evidence does not suggest that the extent of the Veteran's disabilities is such that consideration of a TDIU on an extra-schedular basis is warranted. The Board acknowledges the Veteran's criticism of the aforementioned VA examiner's opinions that her service-connected disabilities do not prevent her from obtaining a substantially gainful occupation. The Board emphasizes, however, that the examiners have identified the extent of the Veteran's function (as demonstrated during physical examination of the Veteran and documented in VA treatment records and examination reports), and based upon such demonstrated function, opined that the Veteran remains able to perform tasks that do not require manual labor or physical exertion. Certainly, a determination of the severity of the Veteran's service-connected heart and pelvic disabilities and any associated functional impairment and physical limitations are questions upon which a physician may be expected to provide probative opinions. As such, the Board assigns great probative weight to the VA examiner's essentially uncontradicted December 2010 and May and October 2012 VA examinations and opinions. In this regard, as noted above, the Veteran's primary care physician's opinions that she is unemployable relate the opinion to multiple service and non service-connected disabilities. Moreover, her primary care physician did not provide any supporting rationale for those opinions. Thus, they are not entitled to any probative weight. The Board is cognizant of, and sympathetic to, the Veteran's assertions that she is unable to obtain or maintain substantially gainful employment. Nonetheless, the fact that a veteran is unemployed or has difficulty obtaining employment is insufficient, in and of itself, to establish unemployability. The relevant question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Here, the weight of the evidence of record does not support a finding that the Veteran's service-connected disabilities, in and of themselves, render her unable to secure and follow a substantially gainful occupation. As such, the evidence does not show any basis upon which to refer this matter to the Director, Compensation and Pension Service, for consideration of a TDIU on an extra-schedular basis. Accordingly, the preponderance of the evidence is against his claim of entitlement to a TDIU, and the claim must be denied. While the appellant is entirely competent to report her symptoms both current and past, she has presented no competent clinical evidence that solely her service-connected heart and pelvic disabilities prevent her from obtaining or maintaining a substantially gainful occupation. The Board finds that the appellant as a lay person, is not competent to provide an opinion as to whether solely her service-connected disabilities prevent her from obtaining or maintaining a substantially gainful occupation. While the Veteran did serve as a medic during service, since her discharge in 1990, she has worked in a non medical occupation or been unemployed. There is no indication that she has received any ongoing medical education or training, other than her own electronic research of medical literature, such as to qualify her as competent to render an opinion as to the occupational effects related to her service-connected disabilities, especially in light of her multiple medical service-connected and non service-connected conditions. In the absence of evidence indicating that the appellant has the medical training to render medical opinions, the Board must find that her contentions with regard to the occupational and functional effects of her service-connected heart and pelvic disabilities to be of no probative value. See also 38 C.F.R. § 3.159(a)(1) (2012) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the appellant in support of this claim are not competent evidence of unemployability due solely to service-connected disability. In this circumstance, the Board gives more credence to the VA medical opinions, as they were rendered after a thorough review of the Veteran's claims file and the history of the claimed disability. The appellant has been accorded ample opportunity to present competent evidence in support of her claim. She has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002). Because the competent evidence of record does not substantiate that the Veteran's service-connected disabilities result in an inability to obtain or maintain a substantially gainful occupation, the claim must be denied. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). ORDER Entitlement to a TDIU at any time during the claim is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs