Citation Nr: 1316550 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 08-33 952A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for left ear hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for vertigo. 5. Entitlement to an initial evaluation in excess of 50 percent for a psychiatric disorder (rated as an anxiety disorder also diagnosed as posttraumatic stress disorder (PTSD)). 6. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his sister ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from August 1965 to August 1967; he honorably served in combat in the Republic of Vietnam and received the Combat Infantryman Badge (CIB) for that service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2005, May 2008, August 2010 and December 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran has timely initiated the appellate process with respect to the above noted issues. The Veteran and his sister testified at a Board hearing before the undersigned Acting Veterans Law Judge in August 2012; a transcript of that hearing is associated with the claims file. The Veteran additionally provided testimony at a personal hearing before Decision Review Officer (DRO) in September 2009, with respect to solely the increased evaluation issue for his psychiatric disorder; a transcript of that hearing is also associated with the claims file. The Board notes that the Veteran was initially service connected for his psychiatric disorder in the November 2005 rating decision, at which time he was assigned a 10 percent evaluation for that disability, effective June 24, 2005-the date he filed for service connection. During the pendency of his appeal, the Veteran's psychiatric disorder has been increased to 50 percent disabling, effective June 24, 2005, in an August 2010 rating decision. The Board has recharacterized the issue on appeal in order to reflect this award of benefits. The issues of service connection for hypertension and bilateral lower extremity peripheral neuropathy, to include either separate evaluations for or as secondary to service-connected diabetes mellitus, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of service connection for left ear hearing loss, vertigo, increased evaluation for a psychiatric disorder, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran is currently diagnosed with right ear sensorineural hearing loss and tinnitus. 2. The Veteran served in combat and was exposed to acoustic trauma. 3. The evidence of record is in equipoise with regards whether to the Veteran's right ear hearing loss began in or is the result of his military service, to include acoustic trauma therein. 4. The Veteran's tinnitus originated in service. CONCLUSIONS OF LAW 1. Resolving benefit of the doubt in favor of the Veteran, the criteria establishing service connection for right ear hearing loss have been met. 38 U.S.C.A. §§ 1110, 1111, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 2. The criteria establishing service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 1111, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). In light of the favorable decision to grant service connection for right ear hearing loss and tinnitus, as discussed below, the Board finds that no further discussion of VCAA is necessary at this time. Such represents a full grant of benefits sought on appeal as to those issues. Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). "[L]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and sensorineural hearing loss becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). On appeal, the Veteran avers that he had no hearing loss prior to enlistment into service. During service, he indicated that he was in combat, and that he was exposed to small arms fire, howitzers and mortars. He related at least one incident in which a mortar landed near him and resulted in his tinnitus, which has been constant since that time. He has stated that his hearing loss began either in service or shortly after his discharge from service and has progressively worsened over time. In support of these statements, he has submitted statements from his mother, sister and a childhood friend which document that the Veteran did not have hearing loss prior to service and that after his return, his hearing was not the same and that he complained of both hearing loss and buzzing in his ears. Such complaints have been consistent since his return from service, according to those statements. On enlistment into service, the Veteran was noted has having a 30 decibel loss at 4000 Hertz (Hz) on his enlistment, but otherwise generally normal hearing. The Veteran denied having any hearing loss or other ear trouble on his report of medical history at that time. During the Veteran's service, there are no service treatment records for any hearing, tinnitus, or other ear problems. In July 1967, the Veteran had a normal ear, nose and throat examination, during which the doctor indicated that the Veteran's audiological examination was normal. The Veteran's separation examination in July 1967 demonstrates a 30 decibel loss in the right ear at 4000 Hz and a 20 decibel loss at 6000 Hz. Again, the Veteran's report of medical history does not reveal any complaints of hearing loss, tinnitus, or any other ear problems on separation from service. In September 2006, the Veteran underwent a private audiological evaluation with Dr. A.H., Au.D, CCC-A. In a letter, she noted that the Veteran was currently diagnosed with bilateral sensorineural hearing loss for greater than ten years, and also suffered from bilateral tinnitus. She noted that his otologic and familial histories were unremarkable and that the Veteran had a previous history of noise exposure. She noted that the Veteran provided a documentation of a history of high-frequency sensorineural hearing loss bilaterally, and that he reported he was exposed to loud sounds when he was serving in the military. She stated that it was "more likely than not his hearing loss is a result of the acoustic trauma he has suffered." The Veteran underwent a VA audiologic examination in December 2007. The examiner noted that she reviewed the claims file and the Veteran's service medical records. She noted that the entrance examination demonstrated normal hearing bilaterally from 500-6000 Hz, with the exception at 4000 Hz in the right ear. She also noted that same mild dip at 4000 Hz in the right ear at separation, but that his separation audiogram was otherwise normal bilaterally. She noted the July 1967 ear, nose and throat examination that noted normal hearing as well. She noted Dr. A.H.'s letter and opinion. During the examination, the Veteran reported decreased hearing acuity which was first noted by his parents following his service. He reported that his hearing loss has been progressive and that he has the greatest difficulty with television and discrimination of speech. He also reported a history of constant bilateral tinnitus since service. The Veteran denied any history of ear infections, surgery, familial hearing loss, head trauma, previous hearing aid use, or occupational/recreational noise exposure. He did report, however, combat noise exposure, such as mortar shells, in service. After audiological evaluation, the VA examiner diagnosed the Veteran with normal hearing from 250-2000 Hz in the right ear, but with mild sloping to severe sensorineural hearing loss 3000-8000 Hz; and normal hearing from 250-3000 Hz in the left ear, but mild sloping to moderately-severe sensorineural hearing loss 4000-8000 Hz. She noted that the Veteran's pre-induction testing indicated hearing within normal limits except for a mild dip at 4000 Hz in the right ear and normal hearing in the left ear. She noted that there was no change in the pure-tone thresholds at the time of separation from service. She opined that the Veteran's currently diagnosed hearing loss was not caused by or the result of his military service. "Although a medical statement provided by an outside provider stated that it is more likely than not that the Veteran's hearing loss is a result of the acoustic trauma he suffered, it should be noted that the examiner did not have access to the Veteran's pre-induction and separation recorded which revealed no change in hearing acuity between the two examinations." She also noted that the Veteran's claimed tinnitus was not the result of his military service as there is no evidence of record to support the Veteran's tinnitus claim. The Veteran's private audiologist, Dr. A.H., submitted another July 2010 letter, which noted that she had monitored the Veteran's hearing loss on a regular basis since 2005, and that he was most recently evaluated on May 2010. She reiterated the Veteran's longstanding history of decreased hearing bilaterally in the high frequencies, reportedly due to a significant history of noise exposure. He also suffered from bilateral tinnitus which was common with noise exposure. His ontological and familial histories were unremarkable. She further stated that "results indicate a hearing loss that is often associated with noise exposure and with his history of gunfire and use of firearms without noise protection, a hearing loss like this can be expected." On the basis of the foregoing, the Board finds that service connection for right ear hearing loss and tinnitus are warranted. First, the Board has reviewed the private and VA audiological results of record in this case. After review of those documents, the Board has determined that at this time only the Veteran's right ear manifests a hearing loss under VA regulations. See 38 C.F.R. § 3.385 (2012). Next, the Board notes that the Veteran's right ear sensorineural hearing loss was not diagnosed within one year of discharge from service and therefore, service connection cannot be granted on a presumptive basis in this case. See 38 C.F.R. §§ 3.307, 3.309. The Board, however, will consider other relevant theories of entitlement at this time. See Combee v. Principi, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Board acknowledges that the Veteran has been diagnosed with right ear sensorineural hearing loss and tinnitus. Therefore, the first element of service connection has been met. Likewise, the Board acknowledges that the Veteran has stated that he was exposed to small arms, mortar and howitzer fire during his period of service; the Veteran was awarded the CIB for his participation in combat in the Republic of Vietnam. He also indicated that he had a mortar hit close to him and that he had tinnitus during service which had been constant since that time. The Board finds these statements by the Veteran to be highly competent, credible and probative, particularly in light of his combat service; such are of the types, places and circumstances contemplated by his combat service. See 38 U.S.C.A. §§ 1154(b) (West 2002). Thus, the second element of service connection has been met. The Board turns to the third element-the nexus requirement-at this time. With regards to this, the Board notes that in cases where VA has recognized a chronic disability under 38 C.F.R. §§ 3.307 and 3.309, 38 C.F.R. § 3.303(b) absolves the Veteran from having to satisfy the nexus requirement if satisfactory evidence of continuity of symptomatology exists. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) only applies to the listed chronic disabilities in 38 C.F.R. §§ 3.307 and 3.307, otherwise continuity of symptomatology cannot abrogate the need for satisfactory of the nexus requirement). Thus, the Board can consider continuity of symptomatology with regards to the Veteran's right ear sensorineural hearing loss, but not with regards to his tinnitus. The Veteran indicated either that his hearing loss began during service or shortly after service, but that it has gotten progressively worse over the years. The Veteran's family and friends' statements also indicate that his hearing loss has been continuous since he returned from service. The Board notes that the Veteran, his friends and his family are competent to testify as to the symptomatology they have observed during and after military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). The Board additionally finds that this evidence is credible. However, these statements do not unequivocally demonstrate that his hearing loss began in service, but that it could have began after military service as well. The Veteran's separation audiological examination demonstrates that he had normal hearing and that his audiometric results were very similar to his pre-induction results. Thus, the Board cannot find a chronic disability that began in service and has been continuous since discharge therefrom. See 38 C.F.R. § 3.303(b). Notwithstanding such a finding, the above lay evidence is still probative and weighs in favor of a finding that the Veteran's bilateral hearing loss is related to his military service. Other evidence of record which supports this finding are the September 2006 and July 2010 letters from Dr. A.H. which note that the Veteran's bilateral hearing loss and tinnitus were more likely than not related to his acoustic trauma in service. In fact, her July 2010 letter noted that the noise exposure of the type that the Veteran described would "be expected" to result in the type of hearing loss that he exhibited. The Board does note that her opinions are slightly devalued in their probity by the fact that she did not review the Veteran's service medical records, to include his enlistment and separation audiological examinations. The VA examiner's opinion weighs against the finding that his hearing loss and tinnitus were the result of his military service. The examiner specifically reviewed the claims file and the service medical records; she noted the Veteran's service medical records did not demonstrate any treatment for, complaints of, or findings of any bilateral hearing loss or tinnitus during military service. She rejected the noise exposure in service as a possible etiology, and Dr. A.H.'s opinion thereto, on the basis that no hearing loss was demonstrated in service. With regards to the Veteran's right ear hearing loss, the Board finds that the evidence is in equipoise with regards to whether the Veteran's right ear hearing loss began in or was the result of military service. Specifically, the Board notes that in-service hearing loss is not necessary in order to award service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). It does not appear that the VA examiner's opinion contemplates that hearing loss may not have manifested in service, but potentially was a gradual onset, such as the Veteran and his family and friends have attested to throughout the record. Moreover, while Dr. A.H.'s opinions are somewhat less probative as a result of her lack of review of the service treatment records, her opinion is still probative as it notes that the type of hearing loss the Veteran has would be "expected" from his military service noise exposure; the Board additionally notes the lack of any other type of noise exposure of service from which the Veteran's sensorineural hearing loss could be "expected" from. In light of these deficiencies in both opinions and the lay evidence of record, the Board finds that the evidence of record on whether his right ear hearing loss began in or is the result of military service is in equipoise. By resolving doubt in favor of the Veteran, the Board finds that service connection for right ear hearing loss is warranted on the evidence of record. See 38 C.F.R. §§ 3.102, 3.303. Turning to the evidence of record with regards to the tinnitus, the Board notes that he has testified that his tinnitus began in service and has been constant since that time; such tinnitus began as a result of a mortar blast landing next to him. While the VA examiner's opinion does not relate the Veteran's tinnitus to service, such an opinion is based on the lack of any evidence of record to support his claim; the VA examiner's evidence specifically does not contemplate this lay evidence of a combat incident which the Board has found to be highly competent and credible. Therefore, that opinion is based on a faulty rationale and is of no probative value with regards to the etiology of the Veteran's tinnitus. Dr. A.H's September 2006 letter gives no opinion with regards to the Veteran's tinnitus, but her July 2010 letter states that tinnitus is common with noise exposure. While she does not explicitly state that the Veteran's tinnitus is the result of his in-service noise exposure, Dr. A.H. has implied that it is. Because of this evidence, particularly when coupled with the Veteran's highly probative, credible and competent evidence that his tinnitus has been constant since it began in service with that mortar blast, the Board finds that the weight of the evidence in this case weighs in favor of a finding that the Veteran's tinnitus began during military service. Accordingly, the Board finds that service connection for tinnitus is warranted on the evidence of record. See 38 C.F.R. §§ 3.102, 3.303. In so reaching those conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for right ear hearing loss is granted. Service connection for tinnitus is granted. REMAND Initially, with regards to the claim of service connection for vertigo, the Board notes that claim was denied in a December 2011 rating decision. In a February 2012 correspondence, the Veteran stated that he disagreed with the denial of his vertigo claim. As of the time of this decision, it does not appear that a statement of the case regarding that matter has been provided to the Veteran. Since the Veteran properly submitted a notice of disagreement within a year of the denial of service connection for vertigo, he has properly initiated the appeals process with respect to that claim. See 38 C.F.R. § 20.200 (2012). Accordingly, VA has a duty to issue a statement of the case on that issue so that the Veteran may complete an appeal by filing a Substantive Appeal. See Manlincon v. West, 12 Vet. App. 238 (1999). Therefore, a remand is necessary as to that issue. Turning to the left ear hearing loss claim, the Board notes that as found above, the Veteran's audiometric data at this time did not meet the criteria necessary under 38 C.F.R. § 3.385 for a hearing loss disability. However, the Veteran did state that his conditions had worsened since his last VA examination during the appeal period. The Board therefore finds that the left ear hearing loss claim must be remanded at this time in order to afford the Veteran another VA audiological examination to determine whether his left ear hearing loss has risen to the level of a hearing loss disability under VA regulations. See Palczewski v. Nicholson, 21 Vet. App 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity); Caffrey v. Brown, 6 Vet. App. 377, 381 (1995). With regard to the psychiatric claim, the Veteran last underwent a VA examination of that disability in January 2010. In a December 2011 correspondence, the Veteran stated that he did not understand VA's decision not to increase his psychiatric disorder and indicated that he thought he should be assessed as 70 percent disabling; he indicated that he did not have any friends, was alone most of the time, did not sleep very well, and was always checking doors and windows. He also stated that his conditions have gotten worse. In light of this statement, and the Veteran's testimony at the August 2012 hearing, the Board finds that it appears that his psychiatric disorder may have potentially worsened since January 2010 and that a remand is necessary at this time in order to afford the Veteran another VA examination which assesses his current nature and severity of that disability. See Palczewski v. Nicholson, 21 Vet. App 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity); Caffrey v. Brown, 6 Vet. App. 377, 381 (1995). Finally, in light of the above grants of service connection and the remand for a new evaluation for PTSD, the Board finds that making a determination on his claim for TDIU at this time would be premature. Accordingly, the Board finds that his TDIU claim is inextricably intertwined with the rating issues of his newly-awarded bilateral hearing loss and tinnitus, as well as his claim for increased evaluation for his psychiatric disability. Accordingly, the Board must also remand the claim for TDIU at this time. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Ongoing private, VA and Vet Center treatment records should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim); Dunn v. West, 11 Vet. App. 462, 466 (1998) (Vet Centers are considered VA facilities for the purposes of the duty to assist in obtaining records, specifically citing Bell). Accordingly, the case is REMANDED for the following action: 1. Undertake all actions required by 38 C.F.R. § 19.26 (2012), including issuance of a statement of the case, so that the Veteran may have the opportunity to complete an appeal on his claim of service connection for vertigo (if he so desires) by filing a timely substantive appeal. The issues should be returned to the Board only if a timely substantive appeal is received. 2. Obtain any relevant VA treatment records from the Northport VA Medical Center, or any other VA medical facility that may have treated the Veteran, since October 2011 and associate those documents with the claims file. 3. Obtain any relevant Vet Center treatment records from the Nassau Vet Center, or any other Vet Center that the Veteran may have been treated by, which are not already of record, and associate those documents with the claims file. 4. Ask the Veteran to identify any VA, Vet Center, or private treatment that he may have had for his psychiatric disability, which are not already of record. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 5. Schedule the Veteran for a VA examination to determine the current nature and severity of his psychiatric disability and its effect on his social and occupational functioning. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. The examiner should indicate all symptomatology associated with the Veteran's psychiatric disability, and provide a Global Assessment of Functioning score. The examiner should additionally opine whether the Veteran's psychiatric disability more like, less likely, or at least as likely as not (50 percent or greater probability) precludes him from obtaining and maintaining substantially gainful employment. A rationale for any opinion expressed must be provided. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 6. Schedule the Veteran for a VA audiologic examination to determine the current nature and severity of his left ear hearing loss and to determine whether such is related to military service. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. After review of the claims file and examination of the Veteran, the examiner should offer an opinion as to whether any left ear hearing loss present is etiologically related to service. A rationale for any opinion expressed must be provided. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 7. Following the above development, the RO/AMC should review the claims file and readjudicate the Veteran's claims of service connection for left ear hearing loss, increased evaluation of his psychiatric disability and entitlement to TDIU. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs