Citation Nr: 1318000 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 10-37 322 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an extraschedular rating (evaluation) for bilateral hearing loss. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant (Veteran) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from July 1962 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2009 and August 2010 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. In January 2011, the Veteran presented testimony relevant to the appeal at a hearing held before a Decision Review Officer (DRO) at the RO in Houston, Texas. In May 2012, the Veteran's representative presented argument on the Veteran's behalf at a Board hearing held before the undersigned Veterans Law Judge (VLJ) at a VA office in San Antonio, Texas. The Veteran was not present for the Board hearing. Transcripts of the hearings are of record. 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) requires that the VA employee who conducts 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. At the DRO hearing, the issue on appeal was noted to involve the evaluation of the Veteran's bilateral hearing loss, which includes consideration of an extraschedular rating. The Veteran provided hearing testimony regarding the severity of his hearing loss disability and its effect on his former employment as an owner of an insurance business. During the course of the hearing, the Veteran stated that he was scheduled to undergo audiological testing in the near future. The DRO informed the Veteran that he would wait for the results of the hearing evaluation and consider those records when making a determination. There was no indication that there was any other evidence that may have been overlooked or was missing from the record in connection with the appeal at that time. At the Board hearing, the undersigned VLJ identified the issue on appeal as entitlement to an initial disability rating higher than 10 percent disabling for service-connected bilateral hearing loss, which includes consideration of a higher rating on an extraschedular basis. The undersigned VLJ asked questions to help direct the Veteran's representative to more adequately portray the functional impairment associated with the Veteran's hearing loss disability. The undersigned VLJ also held the record open for thirty (30) days following the Board hearing in response to the representative's request to allow the additional opportunity to obtain an updated audiogram test; however, no additional evidence was received during the 30-day period. The possibility of, and requirements for, referral for consideration of an extraschedular rating were also discussed. The issue on appeal (i.e., entitlement to an extraschedular rating) was sufficiently identified at both hearings, and the Veteran provided testimony relevant to the initial rating appeal. The DRO specifically obtained updated VA treatment records after considering the Veteran's hearing testimony and considered the records when deciding the claim. At the time of the Board hearing, the undersigned specifically suggested the submission of additional evidence such as recent audiometric testing evidence, and remanded the claim for extraschedular consideration. In consideration of the foregoing, the Board finds that the DRO, as well as the undersigned VLJ, complied with the requirements of 38 C.F.R. § 3.103(c)(2). In an October 2012 Board decision, the undersigned VLJ denied an initial rating in excess of 10 percent for bilateral hearing loss on a schedular basis and, as noted above, remanded the issue for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b) after considering the representative's request for such consideration at the Board hearing due to the Veteran's difficulty conversing on telephones and the decision to sell his business and retire early due to hearing loss. As explained below, a negative determination was received from the Chief of the Compensation Service on the extraschedular issue. FINDINGS OF FACT 1. The schedular criteria are inadequate to rate the additional occupational impairment caused by the Veteran's hearing loss disability because the schedular criteria does not consider the significant effects of hearing loss on the Veteran's former occupation as the owner and manager of an insurance agency, the limited speech amplification with hearing aid usage in a sedentary work environment, or the Veteran's inability to hear speech with the better left ear that is missed by the poorer right ear from the direction of the right side. 2. The Veteran's hearing loss disability caused marked interference with his former employment as an owner and manager of an insurance agency beyond that contemplated by the schedular rating criteria that is consistent with the degree of impairment contemplated by a 20 percent extraschedular disability rating. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent extraschedular rating for bilateral hearing loss have been approximated for the entire rating period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 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 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). Proper notice from VA 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. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a statement of the case (SOC) or supplemental statement of the case (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, the Veteran is challenging the initial disability rating assigned following the grant of service connection for bilateral hearing loss in the February 2009 rating decision and the August 2010 DRO decision. The Court has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the claim for service connection, is needed under the VCAA. Nonetheless, in the December 2008 VCAA notice letter sent in connection with the original service-connection claim, the RO advised the Veteran how VA determines the disability rating once service connection has been established. In particular regard to the extraschedular component, the Veteran was advised that, in rare cases, a disability level other than the levels found in the schedule for a specific condition could be assigned if the impairment was not adequately covered by the rating schedule. The Veteran was also advised that VA considered evidence pertaining to the nature and symptoms of the disability, the severity and duration of the symptoms, and the impact of the disability and symptoms on employment in assigning the disability rating. The Veteran was requested to submit information about on-going treatment, Social Security determinations, and statements from employers as to job performance, lost time, and other information regarding how the disability affects the ability to work. The Veteran and the representative have been provided with a copy of the above rating decisions, the SOC, and SSOCs, which cumulatively included a discussion of the facts of the issue of entitlement to an extraschedular rating, pertinent laws and regulations, notification of the bases for the decision, and a summary of the evidence considered to reach the decision. The Veteran through the representative has demonstrated actual knowledge of the evidence necessary to substantiate the claim for a higher initial rating on an extraschedular basis. See May 2012 Travel Board hearing transcript, pages 3-5; see Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (Court was convinced that the appellant and his representative had demonstrated actual knowledge of the information and evidence necessary to establish the claim). The Veteran has been provided with ample opportunity to submit evidence and argument in support of the claim and to participate effectively in the processing of the claim during the course of this appeal. In consideration of the foregoing, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the RO afforded the Veteran with medical examinations in connection with the initial rating claim in January 2009 and August 2010. The medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the Veteran's hearing loss. The medical examiners took a thorough history of the hearing loss disability from the Veteran, including history of onset, diagnosis, report of symptomatology, other limitations, and treatment. An adequate description of the functional effects of the Veteran's hearing loss was noted. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The medical examiners had adequate facts and data regarding the history and condition of the disability. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). There has not been a material change in the condition of the Veteran's hearing loss disability since the most recent examination. For these reasons, the Board finds that the medical examination reports are adequate for rating purposes, and there is no need for further medical examination. Also, treatment records adequately identified as relevant to the appeal have been obtained, or otherwise submitted, and are associated with the record. There are no additional treatment records pertinent to the Veteran's appeal found in the Virtual VA folder. The Veteran has offered testimony before the DRO and the representative has provided additional argument before the Board regarding the severity of the Veteran's hearing loss disability. In the October 2012 decision, the Board denied an initial rating in excess of 10 percent for bilateral hearing loss on a schedular basis. The Board also remanded the issue of entitlement to an extraschedular rating for bilateral hearing loss for referral to the VA Undersecretary for Benefits or the Director of Compensation and Pension Service pursuant to the provisions of 38 C.F.R. § 3.321(b), for consideration of whether an extraschedular evaluation for service-connected bilateral hearing loss is warranted. Such bifurcation of a claim generally is within the VA Secretary's discretion and, in this case, involved the bifurcation of a schedular rating for hearing loss and an extraschedular rating for hearing loss. Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff'd, 631 F.3d 1380 (Fed. Cir. 2011) (holding that it is permissible to bifurcate a claim and to adjudicate the distinct theories of entitlement separately); see also Locklear v. Shinseki, 24 Vet. App. 311 (2011) (holding that bifurcation of a claim generally is within VA's discretion). The Veteran has not been prejudiced by the Board's adjudication of the initial rating appeal as two issues (i.e., a schedular rating for hearing loss and an extraschedular rating for hearing loss) because any final decision of the Board is appealable to the Court. Tyrues, 23 Vet. App. at 178 (overruling Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) to the extent that "the Court retains its discretion to determine at the threshold that a claim or theory denied by the Board in any such decision or portion of a decision on review is so inextricably intertwined with matters still pending before VA that it should be remanded to VA to await development or disposition of a claim or theory not yet finally decided by VA"). Pursuant to the Board's October 2012 Remand order, the Appeals Management Center (AMC) referred the issue of entitlement to an extraschedular rating for hearing loss to the Chief of the Compensation Service in accordance with 38 C.F.R. § 3.321(b). The February 2013 determination is of record. After consideration of the Chief of the Compensation Service determination, the AMC denied the appeal for an extraschedular rating in a February 2013 SSOC. Neither the Veteran nor the representative has made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim adjudicated herein. The Board further finds that there has been compliance with the prior remand order. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In view of the foregoing, the Board will proceed with appellate review. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). In a claim for a higher original rating after an initial award of service connection, all the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2 (2012). Extraschedular Rating for Hearing Loss The Court has set forth a three-step analysis for analyzing extraschedular rating issues. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extraschedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Thun, 22 Vet. App. at 115. Therefore, initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability and the established criteria found in the Rating Schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is adequate, and no referral is required. In the second step, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by 38 C.F.R. § 3.321(b)(1) (i.e., marked interference with employment and frequent periods of hospitalization). Id. at 116. When the Rating Schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred for a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the referral to the Chief of Compensation Service was accomplished in the Board's October 2012 remand. The Chief of Compensation Service considered an extraschedular rating. The issue of extraschedular rating for hearing loss has been adjudicated, and the case has been returned to the Board for appellate adjudication of the extraschedular rating issue. Extraschedular Rating Analysis for Bilateral Hearing Loss In October 2012, the Board determined that this case suggested an exceptional or unusual disability picture with interference with employment that may render impractical the application of regular schedular standards. The Board remanded the issue on appeal for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). In a February 2013 determination, the Chief of the Compensation Service considered the evidence in the claims file and concluded that there was no unusual or exceptional disability picture shown so as to render the application of the regular schedular rating standards impractical. The Chief of the Compensation Service found that the Veteran's current employment picture showed that he was currently retired and that he had decided to sell his business because of age and hearing difficulties. The Chief then found that the medical evidence of record did not demonstrate that the limitation caused by the Veteran's service-connected hearing loss disability applied to physical job requirements or ruled out the ability to work in a sedentary environment with the use of hearing aids. After considering the February 2013 determination, the AMC denied the Veteran's appeal for an extraschedular rating; therefore, the question of whether the Veteran's hearing loss disability is entitled to a higher initial rating on an extraschedular basis has first been adjudicated by the Chief of the Compensation Service, and the Board may now proceed to evaluate the merits of the appeal. See Anderson v. Shinseki, 22 Vet. App. 423, 427-28 (2009) (the Board has jurisdiction to review determinations of the Director regarding a veteran's entitlement to an extraschedular rating). Regarding the first step of the extraschedular analysis, the Board finds that the evidence is in equipoise on the question of whether the schedular criteria are adequate to rate the Veteran's hearing loss disability. In evaluating the Veteran's initial rating appeal on an extraschedular basis, the Board has considered the symptoms and functional impairment pertaining to the Veteran's bilateral hearing loss disability as shown by the lay and medical evidence of record. There is evidence in favor of finding that the schedular criteria for hearing loss reasonably describe the disability level and symptomatology associated with the Veteran's hearing loss disability. At the DRO hearing, the Veteran complained that he had difficulty hearing when conversing with others on the telephone and on speakerphone. See January 2011 DRO hearing transcript, page 3. Speech discrimination is defined as the ability to recognize spoken words, as measured by speech audiometry. See Dorland's Illustrated Medical Dictionary 527 (30th ed. 2003). The schedular criteria for evaluating a hearing impairment require consideration of speech discrimination, in addition to audiometric data. 38 C.F.R. §§ 4.85 (2012). The Veteran's speech discrimination scores as demonstrated at the January 2009 and the August 2010 VA audiological examinations were specifically considered in the assignment of the current 10 percent schedular evaluation (rating). Thus, some of the hearing loss symptomatology reported at the Board hearing is contemplated in the currently assigned 10 percent schedular rating. Additionally, the representative stated at the Board hearing that the Veteran had received new hearing aids in February 2011 and had reportedly had some improvement with the adjustment. See May 2012 Board hearing transcript, page 3. This is consistent with the February 2011 VA audiological note included in the record, which shows that the Veteran reported improved speech intelligibility and sound quality with new hearing aids at that time. This evidence indicates that the Veteran's ability to hear speech has been improved with amplification through the use and adjustment of new hearing aids since the February 2011 VA medical examination. Nevertheless, there is evidence weighing against finding that the schedular criteria are adequate to rate the Veteran's hearing loss disability. At the DRO hearing, the Veteran testified that the hearing loss disability had prevented him from conversing accurately with clients on the telephone and by speakerphone about financial matters and insurance protection. As the Veteran worked in a sedentary environment and frequently communicated with others by telephone, and the Veteran's hearing testimony regarding how the hearing loss disability impacted his ability to conduct the business of the insurance agency is credible, the Board finds that the hearing difficulties at work resulted in a unique work impairment under the facts presented in this case beyond what is contemplated in the schedular criteria. Indeed, at the DRO hearing, the Veteran testified that he often had to guess the words spoken by others during conversations and ultimately decided to sell the insurance business and retire early because guessing was not good enough when dealing with financial matters affecting the lives of his clients. See January 2011 DRO hearing transcript, page 3. The Veteran also testified that the use of hearing aids did not greatly improve his ability to hear. The Veteran's testimony is generally supported by the February 2011 VA audiology note, which shows that the treating VA audiologist advised the Veteran of the "realistic expectations" for hearing amplification in light of the limitations imposed by his hearing loss when being fitted for hearing aids. Thus, despite the evidence showing some improved hearing amplification with use of hearing aids, the Board resolves reasonable doubt in the Veteran's favor in finding that the use of hearing aids did not significantly improve the Veteran's ability to hear speech while conducting business in a sedentary environment. The Board also notes that the Veteran has severe right-sided hearing loss. The hearing loss demonstrated by the Veteran is unique in that some hearing loss is apparently not recognized by the schedular criteria. as indicated in the separate Board decision addressing the schedular rating for the Veteran's bilateral hearing loss, the audiological findings in this Veteran's case reflect a level IX in the right ear and level II in the left ear, which results in only a 10 percent schedular rating for hearing loss in both ears, despite the much higher severity of hearing loss in the right ear. The schedular criteria determination using the schedular rating percentages of Table VII at 38 C.F.R. § 4.85 incorporates the implicit concept that the better ear can always hear conversation even when the worse ear is unable to hear, an assumption that is not supported in this particular Veteran's case. For example, Table VII assigns only a 0 percent rating for level IX hearing in the worse ear with a level I hearing in the better ear, which reflects that a veteran can have very significant hearing loss to level IX in one ear and not receive any schedular compensation for that hearing loss. Another example is that Table VII assigns only a 10 percent rating for total deafness (level XI) in the worse ear with either a level I or level II hearing in the better ear, rather than assignment of a 50 percent rating that recognizes the total deafness in one ear. The schedular rating criteria's implicit assumption that better ear is hearing much of what the poorer ear is missing does not account for limitations in sound travel based on direction, that is, the schedular rating criteria do not include the concept that hearing ability may be impaired based on sound direction to arrive to the side of the better ear; therefore, such directional impairment would of an extraschedular nature. In this Veteran's case, there is evidence that shows that the (better) left ear is not fully compensating for the loss of hearing in the (worse) right ear. At the Board hearing, the representative stated that the Veteran is unable to understand most of the words during conversation. See May 2012 Travel Board hearing transcript, page 4. The Board finds that the Veteran's account is credible; therefore, the Veteran is likely unable to hear speech in the left ear when it is from the direction of the right side. The schedular criteria do not consider the Veteran's inability to hear with the better left ear, in addition to the inability to hear with the poorer ear, when speech is coming from the right side. This evidence weighs against finding that the schedular criteria adequately rate the Veteran's hearing impairment. Thus, on the one hand, the schedular criteria include speech discrimination scores, which is some recognition of inability to discern speech or words in conversation. The Veteran is also shown to have improved hearing ability when using hearing aids. On the other hand, the Veteran has presented competent and credible evidence showing that hearing amplification with hearing aids is limited and did not significantly improve the Veteran's hearing so that he is able to converse accurately with others in a sedentary work environment, which presents a unique work impairment not contemplated by the schedular criteria. The schedular criteria also do not consider the Veteran's inability to hear speech missed by the better left ear. The evidence shows that the Veteran demonstrates significant hearing loss and very low speech recognition scores, particularly in the right ear. The January 2009 VA audiometric results for the right ear reflect an exceptional pattern of hearing impairment under 38 C.F.R. § 4.86(a). The August 2010 VA audiometric results nearly reflect an exceptional pattern of right ear hearing impairment. The Veteran also demonstrated speech recognition scores for the right ear of 48 percent at the January 2009 VA audiological examination and 40 percent at the August 2010 VA audiological examination, which were significantly lower than the speech recognition score for the left ear at both examinations, and shows significant disparity between the left and right ears. This evidence weighs in favor of finding an exceptional disability picture for hearing loss. For these reasons, and resolving reasonable doubt in favor of the Veteran, the Board finds that the schedular criteria are not adequate to rate the additional impairment associated with the hearing loss disability. The Board next finds that the evidence is at least in equipoise on the question of whether the Veteran's hearing loss disability caused marked interference with his former employment as an owner and manager of an insurance agency beyond that contemplated by the schedular rating criteria. The August 2010 VA audiological examination report reveals that the VA examining audiologist diagnosed moderately severe sensorineural hearing loss in the right ear and mild to moderately severe sensorineural hearing loss in the left ear and opined that the Veteran's hearing disability had "significant effects" on his occupation. When asked to specify the impact of the Veteran's hearing disability on occupational activities and daily activities, the VA examining audiologist noted that the Veteran had hearing difficulty during occupational activities and likely had difficulty hearing and understanding others during daily activities. The VA examining audiologist based the opinion on review of the claims file and interview of the Veteran, as well as the audiometric findings shown on examination, and there is no competent medical opinion to the contrary of record. Thus, the August 2010 VA audiological opinion supports the finding that the Veteran's hearing disability interfered with the ability to hear others during the occupational activities of employment. The Veteran also has a history spanning several decades of wearing hearing aids. At the January 2011 DRO hearing, the Veteran testified that he first started wearing hearing aids "a little over 40 years ago." The Veteran similarly told the January 2009 VA examining audiologist that he had used hearing aids for the past 40 years. Thus, by the Veteran's own account, he began wearing hearing aids approximately at the age of 29. There is no indication in the record that the Veteran's reported history of hearing aid use is not credible. This evidence supports finding that, despite the use of hearing aids, the Veteran was unable to continue to perform all the functions required by his job. The Veteran has further provided hearing testimony regarding the negative effect that the hearing loss disability had on his former occupation in connection with the appeal. At the January 2011 DRO hearing, the Veteran testified that his hearing loss deteriorated to the point that he could no longer accurately converse with people on the telephone or on a speakerphone. He stated that he had difficulty understanding a lot of words and questions and had to have them repeated. He further stated that, although he had "become pretty good at guessing" the words of others, he decided to sell his insurance business about five years earlier than planned due to difficulty understanding and discriminating a lot of conversation in background noise even when using hearing aids. See January 2011 DRO hearing transcript, page 3. At the Board hearing before the undersigned, the Veteran's representative reiterated that the Veteran was unable to continue with his insurance business and decided to sell the business about five years earlier than planned due to the extreme difficulty conversing on telephones and with other people as a result of his hearing loss. The representative also referenced the Veteran's low speech recognition score in the right ear and explained that the Veteran reported that he had difficulty understanding a lot of words and questions and had to have them repeated. See May 2012 Travel Board hearing transcript, pages 3-4. The Veteran is competent to provide an account of how the service-connected hearing loss has impacted his employment, and the Board finds the account to be credible; thus, the Veteran's hearing testimony provides further support of marked interference with employment due to service-connected hearing loss. The competent and credible evidence of record shows that the Veteran's bilateral hearing impairment made it difficult for him to manage his insurance business and influenced his decision to sell the business and retire early, although he has demonstrated an ability to "guess words" and improve the ability to hear speech through the use of hearing aids. The August 2010 VA examining audiologist opined that the Veteran's difficulty hearing had a significant impact on his occupation, and the Veteran demonstrates significant hearing loss and low speech recognition scores in the right ear. The schedular criteria assume that the better ear can hear what the poorer ear is unable to hear; however, this may not be true for speech from the direction of the right side. The Veteran also has a history of hearing aid usage spanning over four decades. Although the Veteran has not indicated that he was unable to obtain the information necessary to conduct his insurance business in written form when he was not otherwise able to guess the correct words being used in conversations and when the use of hearing aids was not sufficient for improving the ability to hear speech. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's hearing loss disability has resulted in marked interference with employment. The Board further finds that, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating of 20 percent, but no greater than 20 percent, for bilateral hearing loss, for the entire period of the initial rating appeal. In assigning the extraschedular rating of 20 percent in this case, the Board notes and has applied VA's general rating principles that urge recognition of the actual additional impairment caused by a service-connected disability. See 38 C.F.R. § 4.21 (2012) (rating regulations do not require that all cases show all findings specified by the Rating Schedule, but is important to show the disability and to coordinate rating with impairment of function). In this particular case, while the evidence supports a finding of marked interference with this Veteran's sedentary employment, the interference in this case is limited to some degree of inability to perform specific conversations and interactions in an office (sedentary) environment, rather than such inability in other environments where such abilities are less impairing. Additionally, the evidence shows that the additional impairment caused the Veteran to relinquish only specific functions of his sedentary position limited to dealing with insurance clients. The evidence does not include quantifiable monetary loss or even generally measurable job position or status changes to show more interference with employment than would be recognized by a 20 percent extraschedular rating. The Board notes that all of the Veteran's schedular hearing loss disability warrants only a 10 percent schedular rating; the assignment of an extraschedular disability rating is assigned to recognize the impairment in addition to the schedular rating. The Board notes also that the schedular disability rating of 10 percent in this Veteran's case (based on Maryland CNC speech recognition scores) includes some recognition of loss of speech recognition that cannot also serve as the basis for an extraschedular rating without violating the rule against pyramiding at 38 C.F.R. § 4.14 (2012); therefore, the amount of limitation of speech recognition ability that can be recognized as purely extraschedular, that is, that impacted this Veteran's ability to responsible work with insurance clients, is limited to that unique impairment in his specific occupation and specific employment experience. Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent extraschedular rating for bilateral hearing loss, but no higher, have been approximated for the entire rating period. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.321(b). The 20 percent extraschedular rating under 38 C.F.R. § 3.321(b) is to be assigned in addition to, and separately rated apart from, any schedular rating percentage assigned for hearing loss under 38 C.F.R. § 4.85. The Board has considered evidence of marked interference with employment in awarding an extraschedular evaluation under 38 C.F.R. § 3.321(b), as discussed above; however, to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) of hearing loss and tinnitus is not raised by the Veteran or the evidence of record. A TDIU, while a form of extraschedular rating, involves different factual questions than the extraschedular rating issue decided in this Board decision. See 38 C.F.R. § 4.16 (2012) (inability to obtain or maintain substantially gainful employment due to all service-connected disabilities). In the present appeal, the Board finds that the issue of TDIU has not been reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); 38 C.F.R. § 4.16. The Veteran has testified that he voluntarily chose to retire early due to hearing difficulties, and did not testify or assert that he lost employment due to the service-connected hearing loss disability or is unable to find employment due to hearing loss. He has not alleged and is not otherwise shown to be unable to secure or follow substantially gainful employment due to service-connected disabilities. ORDER An extraschedular evaluation of 20 percent for bilateral hearing loss is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs