Citation Nr: 1319183 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 06-31 657 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUES 1. Entitlement to service connection for a hemorrhoid disability, for accrued benefits purposes. 2. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), in excess of 30 percent prior to September 6, 2006, and in excess of 50 percent on and after September 6, 2006, for accrued benefits purposes. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), for accrued benefits purposes. ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran had active service from October 1964 to June 1970. He died in November 2011. The appellant is the Veteran's widow. She filed an accrued benefits claim in September 2012 and moved to be substituted on the Veteran's appeal. That motion to substitute as the appellant in this case is granted. 38 U.S.C.A. § 5121A (West Supp. 2012). This appeal comes before the Board of Veterans' Appeals (Board) from a December 2005 rating decision of the RO in New York, New York, which granted service connection for PTSD and assigned a 30 percent initial rating, effective August 19, 2004, as well as from a February 2006 rating decision of the RO in New York, New York, which denied service connection for hemorrhoids. The Board issued an April 2010 decision which, in relevant part, remanded these claims for additional development. While these issues were on remand, a 50 percent rating was granted for PTSD for the initial rating period from September 6, 2006. In November 2009, the Veteran's representative presented argument at a Board hearing, chaired by the undersigned Veterans Law Judge, seated at the VA Central Office in Washington, D.C. A transcript of the hearing is associated with the claims file. FINDINGS OF FACT 1. The Veteran had a current disability of recurrent hemorrhoids prior to his death. 2. The Veteran's hemorrhoids had their onset during service. 3. The Veteran's hemorrhoids were related to his active service. 4. For the initial rating period prior to September 6, 2006, the Veteran's PTSD was mild in nature and more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 5. For the initial rating period from September 6, 2006, the Veteran's PTSD was not characterized by occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships. 6. Throughout the initial rating period, the schedular ratings criteria have been adequate to rate the Veteran's PTSD. 7. As of October 2003, the Veteran's service-connected combined for a rating of 60 percent. 8. The Veteran's service-connected disabilities of the low back, lower extremities and right arm, which were the result of multiple injuries incurred in action, have been combined to at least a 60 percent rating throughout the period on appeal from October 2, 2003. 9. For the period from August 19, 2004, service connection for PTSD with a 30 percent rating was in effect, for a combined rating for all disabilities of 70 percent; for the period from March 7, 2005 the combined rating was 50 percent; and for the period from September 6, 2006 the combined rating was 90 percent. 10. The Veteran was not unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities for any period, even when considering the effect of his service-connected disabilities, employment history, educational and vocational attainment, and all other factors relevant to the question. 11. The Veteran had substantially gainful employment for all periods, as indicated by income that exceeded the poverty thresholds. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the appellant's favor, a hemorrhoid disability was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1154(b), 5103, 5103A, 5107, 5121A (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. Prior to September 6, 2006, the criteria for an initial rating in excess of 30 percent for PTSD were not met at any time. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5121A (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. On and after September 6, 2006, the criteria for an initial rating in excess of 50 for PTSD were not met at any time. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5121A (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The requirements for a TDIU have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5121A (West 2002); 38 C.F.R. §§ 3.321, 3.340. 3.341, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran, or by the appellant, or on the appellant's behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the competency, credibility and probative weight of the relevant evidence, both lay and medical, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 C.F.R. § 3.102. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for service connection, increased initial ratings for PTSD, and TDIU. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The claim for service connection for a hemorrhoid disability has been granted, as discussed below. As such, the Board finds that no further duty to notify or assist is required for this issue because the benefit is being fully granted, with no remaining question of law or fact to decide. See 38 U.S.C. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Mlechick v. Mansfield, 503 F.3d 1340 (Fed. Cir. 2007). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and 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). 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. Compliance with the first element requires notice of the five service connection elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C.A. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, a February 2005 letter fully satisfied the duty to notify provisions prior to initial adjudication of the Veteran's claim for service connection for PTSD in December 2005. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Notice was not provided for the TDIU portion of the appeal in a timely fashion. The Veteran was provided adequate notice regarding TDIU under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in a July 2010 letter. He was provided three months to respond and TDIU was adjudicated in an October 2011 Supplemental Statement of the Case. As the appellant has substituted for the Veteran in these claims, she is charged with all notice provided to him. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran identified records from Drs. W., L., and M., which were not obtained, but these pertain to the hemorrhoid claim which has been granted in full. The appellant has at no time referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran was last provided a VA examination in August 2010 for PTSD. The Veteran and the appellant did not report any recent treatment specifically for PTSD other than at VA, records of which are in the file, and the VA treatment records do not suggest a worsening of PTSD after the August 2010 VA examination findings and prior to the Veteran's death in November 2011. The August 2010 examination report provided sufficient evidence to apply the ratings schedule and to determine that the schedular rating is adequate. The August 2010 VA examination report is thorough and supported by VA outpatient treatment records. The examination in this case is an adequate basis on which to adjudicate the claim. Given his death, the Board must rate the psychiatric disability based on the evidence of record. Further remand for an evaluation of the severity of the Veteran's PTSD prior to his death would be futile. No specific VA examination was provided with regard to the TDIU issue. The Veteran's employment and the effects of his service-connected disabilities on his employment were discussed in several VA examination reports for the underlying service-connected disabilities in 2006, 2007, 2008, 2009, and 2010. The record is also supplemented by the Veteran's statements and statements from an employer. These are discussed at length in the TDIU section below. The Board finds that the medical and lay evidence of record are sufficient to determine whether the Veteran was unable to secure or follow any substantially gainful occupation due to his service-connected disabilities. The Board finds that remand for a retrospective medical opinion regarding TDIU is not necessary given the Veteran's death and because there is sufficient contemporaneous medical evidence regarding the impact of the service-connected disabilities on employment. See Chotta v. Peake, 22 Vet. App. 80, 85-87 (2008). The Board is obligated by law to ensure that the RO complies with its directives; 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. Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded these issues in April 2010. The Board instructed that the Veteran be asked to provide the names, addresses, and dates of treatment or examination of all health care providers who have provided treatment for hemorrhoids since discharge from service, to include Drs. W., L., and M., that 1979 VA treatment records from the Northport VA Medical Center (VAMC) be associated with the claims file, that the Veteran be provided a VA examination in association with the hemorrhoid claim, that he be provided adequate notice under 38 U.S.C.A. § 5103(a) with regard to the TDIU claim, that he be provided a VA examination in connection with his PTSD claim, and that all the claims be readjudicated and, if denied, a supplemental statement of the case (SSOC) should be issued. The Board notes that the first three instructions all pertain to the service connection for hemorrhoid disability claim which has been granted, as discussed below. Any error in completing those instructions cannot result in harm to the appellant. The Veteran received notice for the TDIU claim in a July 2010 letter. The appellant has substituted for the Veteran; adequate notice to him satisfies adequate notice for her. The Veteran was provided an August 2010 VA examination in connection with his PTSD claim. The VA examination report is adequate, as discussed above. An October 2011 SSOC was issued which addressed the TDIU issue. The Board finds that the RO complied substantially with April 2010 remand instructions. Further remand for additional development of the prior remand instructions is not warranted. See Stegall. Service Connection for Hemorrhoids Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service connection connotes many factors but basically means that the evidence establishes that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisted such service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Hemorrhoids are not classified as a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Establishing service connection generally requires competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) 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). The Veteran made many statements in support of this claim that he had ongoing hemorrhoid problems. The Veteran's VA treatment records show a history of multiple hemorrhoidectomies. The current disability element is established. See Shedden, 381 F.3d at 1167. The Veteran's statements indicate that he first began experiencing hemorrhoids with bleeding while flying long hours on combat missions in Vietnam. His statements also indicate that he had treatment at an Army Field Hospital. The Veteran did not have the requisite medical experience, knowledge or training to qualify as a medical expert. He could, however, provide lay evidence. Lay persons are competent to provide opinions on some medical issues falling within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Lay 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. See Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board considers hemorrhoids to be among those conditions capable of lay diagnosis, both during service and at the present. His statements are also competent to report recurrent symptoms from service to the present. The Veteran's service treatment records from his period of active service are largely unavailable as they were destroyed in a 1973 fire that occurred at the National Personnel Records Center. In cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Two separation from service physical examination reports from April and September 1970 are of record. The reports do not mention hemorrhoids. The clinical evaluations found his anus and rectum normal. The Veteran completed a report of medical history at the September 1970 examination. He denied piles or rectal disease at that time. There was no specific entry regarding hemorrhoids. Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of such if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Veteran was in receipt of the Distinguished Flying Cross and a Purple Heart. The Veteran's participation in combat is proven. The Veteran was competent to diagnose hemorrhoids. His complaint was that the condition was recurrent, not continuously present; thus, the absence of a notation of hemorrhoids at the separation examination physicals is not fatal to the claim. Moreover, the Veteran's service treatment records have largely been lost. The Veteran reported seeking treatment, but the records to support his claim would have been among the lost records. Finally, the Veteran was a combat veteran. Resolving reasonable doubt in favor of the appellant, the Board finds that the in-service incurrence of hemorrhoids is established. See Shedden. The Veteran reported that he had recurrent hemorrhoids after service, undergoing surgery at a VA Medical Center in the 1970's. A March 1974 VA hospital summary is of record. The Veteran was admitted to the VA Northport Medical Center for hemorrhoids which had developed about seven years prior to admission. He had a large external hemorrhoid which was excised under general anesthesia. He also reported care from three private doctors, Drs. L., W., and M. Records from these doctors were not obtained. The Veteran was competent to report the presence of hemorrhoids and that he sought treatment for them from service to the filing of his claim. The Veteran was seen for an August 2010 VA examination. The Veteran reported a similar history to the above. The report indicates that the examiner reviewed the record, but the examiner appears to have overlooked the 1974 VA hospital summary. The examiner stated that he could not find documentation of hemorrhoidectomy surgery at the Northport Medical Center in the 1970's. This is plainly of record. The examiner indicated that he could not relate the hemorrhoids to service without resort to speculation, given the lack of service treatment records or recent surgical notes from the private doctors. The examiner prepared a September 2011 addendum opinion reviewing the 1974 record. He again concluded that he could not offer an opinion without resort to speculation because most of the Veteran's service treatment records were lost and what remained did not provide documented proof of hemorrhoids during service. Resolving reasonable doubt in favor of the appellant, the Board finds that the symptoms of the hemorrhoid disability have been persistent since service. See Shedden. His reports of persistent symptoms are competent lay evidence. The 1974 hospital summary provided a seven history of hemorrhoids, dating to approximately 1967 and halfway through the Veteran's period of service. This supports the contention of in-service onset of hemorrhoids. The September 2011 VA medical opinion appears to require documentation of hemorrhoids during service as a basis for nexus opinion. This is not a requirement for service connection, particularly not for a combat veteran. See Buchanan, 451 F.3d at 1336. This renders the VA opinions of minimal probative value. In light of competent and credible report of hemorrhoid symptoms in service and since service, and the lack of probative medical evidence against a nexus, the Board finds that the current hemorrhoid disability is related to the in-service hemorrhoid disability as reported by the Veteran. See Shedden. In light of the current disability of hemorrhoids, the in-service incurrence of hemorrhoids, his consistent history of recurrent hemorrhoids since service, and the persistent symptoms of hemorrhoids since service, the Board finds the evidence is at least in equipoise on the question of whether hemorrhoids had their onset during service. Resolving reasonable doubt in the appellant's favor, the Board finds that the criteria for service connection for hemorrhoids are met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Initial Disability Rating for PTSD The appellant contends that the Veteran was entitled to an initial rating in excess of 30 percent for his PTSD prior to September 6, 2006, and in excess of 50 percent on and after September 6, 2006. During his lifetime, the Veteran contended that PTSD was more severe than contemplated by the initial 30 percent prior to September 6, 2006 rating or the initial 50 percent rating on and after September 6, 2006. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2012). The Veteran's service-connected PTSD is evaluated as 30 percent disabling under the General Rating Formula for Mental Disorders, prior to September 6, 2006, and 50 percent disabling on and after September 6, 2006. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, the criteria for a 30 percent disability rating are: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events). The criteria for a 50 percent disability rating are: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting; inability to establish and maintain effective relationships.) The criteria for a 100 percent rating are: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, supra. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a score of 61-70 illustrates "[s]ome mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." Id. A score of 51-60 represents "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 41-50 illustrates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. Initial PTSD Rating prior to September 6, 2006 A 30 percent initial rating is in effect from August 19, 2004 (the effective date of service connection) to September 6, 2006. The Veteran's claim for service connection for PTSD was received on August 19, 2004. In it, he provided a limited description of his symptoms. He stated that he was reclusive and tended to work better by himself, that he suffered from nightmares, and that he was easily startled by any loud noises. The Veteran submitted copies of records related to a 1998 grant of long term disability benefits by a private insurer. An August 1998 letter from an orthopedic surgeon concluded that the Veteran was disabled from his occupation as an insurance salesman due to his knee disabilities. These records do not reference PTSD or psychiatric symptoms. An August 2004 statement indicates that the Veteran was "a bit reclusive" and tended to work better alone. He reportedly suffered from nightmares and was startled by loud noises. The Veteran was seen at a March 2005 VA examination. The Veteran was noted to be employed full time. He married his wife during active service, they had three children, one of whom was still living at home. The Veteran reported that his relationship with his wife and children has been stable and loving for the most part, but that he had never spoken to his family about his military experience. He and his wife belonged to a dining out club and went to restaurants once a month with other couples. The Veteran had one or two other friends, whom he did not consider close, that he saw occasionally. The Veteran owned a boat and went fishing in season. The Veteran reported that he had always shied away from friendships and close relationships. He reported some over-use of alcohol, without significant social or occupational impairment as a result. He did not report contributory post-service stressors, but did state that news of the Iraq war exacerbated his re-experiencing symptoms. The Veteran reported nightmares or dreams about Vietnam several times a week with occasional sleep disturbance. He denied talking to his family or acquaintances about his experiences in Vietnam. He reported feeling guilt, depression, alienation and estrangement since his tour in Vietnam. He found face to face contact with customers in his business difficult to tolerate. At that time, he had no inpatient or outpatient psychiatric history and had never taken psychiatric medication. On mental status examination in March 2005, the Veteran was neatly dressed and appropriately groomed. He was alert and oriented in all spheres. He made good eye contact and displayed behavior appropriate to the interview. His mood was mildly dysphoric; his affect was constricted and somber. He did not report suicidal/homicidal ideation/intent/ plan or any history of assaultiveness. He displayed no impairment of communication or thought process. His speech was spontaneous, relevant, and at normal rate and rhythm. His thinking was logical, goal oriented, and without evidence of formal thought disorder. He denied hallucinations and delusions. Long and short term memory was intact. His attention and concentration were adequate for the examination. He did not report panic attacks, phobias, obsessive thoughts, or rituals that interfered with functioning. He indicated adequate maintenance of personal hygiene and competent management of finances, diet, and other activities of daily living. He reported mild sleep disturbance but not significant fatigue during the day as a result. Judgment and insight were present. The examiner assigned a GAF score of 63, with a 61 to 65 in the past year. The Veteran received some therapy through VA in the period prior to September 6, 2006. The Veteran was seen for intake and initial screening for VA social work therapy in two visits in June and July 2005. The Veteran reported always being bothered by his Vietnam experiences and that he had been able to stifle his emotions. He reported living with guilt that he "didn't do enough" in Vietnam. He had no friendships. He was close only with his wife. He had three children, but he was not close to them. The older children were in their thirties and the youngest had just graduated from high school. The Veteran reported that he used to go out to meet with clients in the insurance business but could no longer do so because of his knees. He reported that he always had a problem with the public and handling "people who complain." He reported nightmares and being up in the middle of the night. The Veteran was not able to relax because of recurrent nightmares and constant knee pain. Similar remarks are contained in October 2005 and February 2006 social work notes. A September 2005 Physician's Questionnaire was completed by a pair of social workers regarding the Veteran's PTSD. They indicated that he had recurrent nightmares of Vietnam trauma, that he was unable to relax, cope with war news, cope with the public, that he had checking and hypervigilance, was angry and irritable and that he had no friends and was not close to his children. They also indicated that he had difficulty in establishing and maintaining effective work relationships. The report states that the Veteran's knee pain was a constant reminder of his crash landings and his belief that he did not do enough. The social workers' entry indicates that the Veteran had both occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks and that he had occupational and social impairment with reduced reliability and productivity due to his PTSD symptoms. They indicated that the current GAF score was 50. A co-worker submitted January and February 2006 statements in support of the Veteran's claims. Neither statement mentions PTSD or PTSD symptoms. Instead, both statements indicate that the Veteran's osteoarthritis had curtailed his mobility and greatly reduced his income. In his February 2006 Notice of Disagreement, the Veteran stated that, because of his nervousness and anxiety, he had begun regular treatment with a social worker through VA. He did not provide additional description of his symptoms at that time. The Board discounts the probative value of the September 2005 Physician's Questionnaire. The social workers reached a conclusion about the Veteran's ability to establish and maintain effective work relationships. Considering the January and February 2006 statements from his employer which do not mention PTSD, this conclusory statement is questionable. Moreover, the March 2005 VA examination was conducted by a clinical psychologist. The Board gives greater weight to the psychologist's opinion than to that of social workers. The Board finds that the overall GAF scores assigned prior to September 6, 2006 support a finding of mild symptomatology. The March 2005 GAF score of 63 and 61 to 65 in the past year is suggestive of mild symptoms, with the individual "generally functioning pretty well." The September 2005 GAF score of 50 rendered by the social workers that is lower than other assigned GAF scores on multiple other occasions. The Board considers the September 2005 social workers' assessment of GAF to be of lower probative value than the GAF reflected in the March 2005 VA examination report by a clinical psychologist which, in addition to the examiner's additional training and expertise in assessing psychiatric symptoms and impairment, was based on a more thorough review of the evidence, made more specific findings, and is more consistent with other assigned GAFs of record. The Board further finds that at no time during the rating period prior to September 6, 2006 has the Veteran's PTSD symptomatology more nearly approximated occupational and social impairment with reduced reliability and productivity, as required for a higher disability rating of 50 percent under Diagnostic Code 9411. The evidence does not demonstrate symptomatology such as flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking. The Veteran functioned independently, appropriately, and effectively in the insurance business. The statements from the Veteran's employer weigh heavily against a finding of higher rating, as they tend to show that the impaired function at work was associated with his osteoarthritis rather than PTSD. The Veteran's 1998 long term disability insurance finding was based on his osteoarthritis as well. Although the Veteran's income was curtailed during this period, he continued to function effectively in a technical business requiring significant public contact. Additionally, the Veteran was married with some social activity. The Board acknowledges his tendency toward social isolation, but his desire for isolation did not impair his effectiveness in social relationships. This tends to show that he did not have difficulty in establishing and maintaining effective work and social relationships. The Veteran did not have legal, financial, or employment problems prior to September 6, 2006 due to his PTSD. The weight of the evidence shows that he did not have disturbances of motivation and mood such that occupational or social impairment resulted. Absent any showing of any of the criteria for a 50 percent evaluation, the preponderance of the evidence of the severity of the Veteran's PTSD is insufficient to support such an evaluation. See 38 C.F.R. § 4.126(a). Initial Rating for PTSD from September 6, 2006 The Veteran underwent a VA examination on September 6, 2006. He reported that he continued to work full-time as an insurance agent, but was penalized financially because he was unable to make face-to-face contact with clients. He reported spending most of his time alone in his office and rarely interacting with other people in his office. He did not report taking excessive time off because of psychiatric symptoms. He had not taken a vacation in eight years. The Veteran spent most of his time alone at home or with his wife. He went fishing occasionally and tried to read. His wife convinced him infrequently to go to social events. He had no legal problems. He did not abuse alcohol or have any history of substance abuse. He had chronic leg and hip pain which contributed to his insomnia and depressed mood. He reported irregular social work visits but did not report substantial remission of symptoms with counseling. He was not on psychiatric medication. He reported more frequent nightmares and intrusive memories about combat, resulting in depression, survivor guilt, and insomnia. He was irritable at home, disliked being with family or acquaintances, and lacked interest in most routine activities. He also complained of persistent and chronic pain. On mental status examination in September 6, 2006, the Veteran was neatly dressed and appropriately groomed. He was alert and oriented in all spheres. He made good eye contact and displayed behavior appropriate to the interview. His mood was mildly dysphoric; his affect was constricted but congruent with thought content. He did not report suicidal/homicidal ideation/intent/plan. He displayed no impairment of communication or thought process. His speech was spontaneous, relevant, and at normal rate, rhythm, and intonation. His thinking was logical, goal oriented, and without evidence of formal thought disorder. He denied hallucinations and delusions. Long and short term memory was intact. His attention and concentration were adequate for the examination. He did not report panic attacks, phobias, obsessive thoughts, or rituals that interfered with functioning. He indicated adequate maintenance of personal hygiene and competent management of finances, diet, and other activities of daily living. He reported chronic insomnia resulting in fatigue during the day. Judgment and insight were present. He reported PTSD symptoms of increased insomnia and nightmares since his prior examination. The examiner assigned a GAF score of 55, reflecting nightmares, irritability, insomnia, depressed mood, and social withdrawal, with a GAF of 51 to 60 in the past year. The examiner characterized the Veteran's PTSD symptoms as "moderate." A June 2007 social work note indicates that the Veteran was more withdrawn. His wife had undergone surgery which became complicated. Her condition had made him feel powerless. The Veteran reported finding a "safety zone" in his office but shunned people. He was not close to his children and said that he chose to be alone. He did not become close to anyone because he did not want to lose anyone. He found his work associates "callous" about Iraq war issues. He reported visiting a son who lived in Arizona once a year and his daughter in North Carolina once a year. His wife visited separately. He reported that he had not discussed his war experiences with his family. Comparisons between Vietnam and Iraq caused him to feel depressed. The Veteran's representative presented argument before the undersigned in November 2009. This hearing did not include a presentation as to PTSD. A May 2010 social work note states that the Veteran was seen for a one hour therapy session for PTSD. He had last been seen for PTSD in June 2007. He requested the session because he was "not doing well." A May 2010 psychiatry history and progress note states that the Veteran was seen complaining of increasing irritability. Although this note did not provide an assessment of his symptoms, a GAF score of 55 was recorded. A Mental Health nursing outpatient note of the same date did record his symptoms. He had no abnormal behavior. His affect was appropriate. His mood was depressed. His thought process was coherent and goal driven. His thought content was appropriate. He denied hallucinations or delusions. He had flashbacks that interfered with his sleep. He reported that he had little motivation. The Veteran submitted a VA Form 9 in June 2010 on which he reported that his condition was worsening. He reported that he had recently been put on medication. He reported becoming increasingly agitated and displaying a complete lack of patience with others, choosing to isolate himself from his family and the public. The Veteran's employer submitted a July 2010 letter that the Veteran's physical disabilities and worsening attention span had diminished his ability to secure sales of new clients to a point of non-productivity. The Veteran had been allowed to maintain his relationship with the firm, but the employer indicated that, if terminated, the Veteran would have little chance of finding new, gainful employment in the insurance industry. The Veteran was seen for a final VA examination in August 2010 for his PTSD. The Veteran reported that he had been forced into part-time work because of physical limitations. He did not attribute his part-time status to psychiatric symptoms and did not report taking time off because of PTSD. His marriage remained stable and loving, but he had considerable anxiety due to his wife's health issues. The mental status examination results were largely as during the September 2006 VA examination, except that he avoided eye contact throughout the interview. The examiner again characterized his symptoms as "moderate," assigning a GAF score of 52 with a GAF of 50 to 55 in the past year. In February 2011, the Veteran submitted a formal TDIU claim. He indicated that his PTSD, osteoarthritis, and hemorrhoids all prevented him from securing or following any substantially gainful employment. His employment history showed that he was terminated by his former employer in November 2010 and had attempted to continue insurance sales on his own. He indicated that he had been unable to find an employer willing to offer him a position. A June 6, 2011 mental health nursing note shows that the Veteran did not have abnormal behavior. His affect was appropriate, his mood depressed, and his thought process coherent and goal driven. He did not have hallucinations or delusions. His thought content was appropriate. He had sleep disturbance, change in appetite, flashbacks and nightmares. He denied suicidal thoughts. A June 6, 2011 psychiatry note stated that he was fully oriented, with a depressed mood, an appropriate, blunted affect, normal attention and concentration, with normal recent and remote memory. The Veteran's thought processes were normal and blocking, with unremarkable content. He did not have suicidal or homicidal ideation, plan, or intent. He had insomnia. His insight, judgment, and impulse control were fair. A GAF score of 50 was assigned. The Veteran was diagnosed with esophageal cancer in June 2011 and began chemotherapy. A June 24, 2011 psychiatry note states that he was fully oriented, with a depressed mood, an appropriate, blunted affect, normal attention and concentration, with normal recent and remote memory. The Veteran's thought processes were normal, with unremarkable content. He did not have suicidal or homicidal ideation, plan, or intent. He had insomnia. His insight, judgment, and impulse control were good. The Board further finds that at no time during the rating period has the Veteran's PTSD symptomatology more nearly approximated occupational and social impairment with deficiencies in most areas, as required for a higher disability rating of 70 percent under Diagnostic Code 9411. The evidence does not demonstrate for any period 70 percent symptomatology such as obsessional rituals, intermittently illogical, obscure, or irrelevant speech, or spatial disorientation. He maintained his grooming and hygiene. He behaved appropriately. The Veteran endorsed depression, irritability, insomnia, fatigue, nightmares, flashbacks, and little motivation but continued to function independently, appropriately, and effectively. The Veteran's former employer complained of a worsening attention span, but his attention and concentration had been repeatedly found intact in treatment notes. The Veteran has a history of appearing for his VA treatment appointments on time and alone. His interactions with VA staff have been appropriate. The Veteran did not have any suicidal or homicidal ideation or any history of violent behavior. Additionally, the Veteran did not have legal problems at that time. When describing his employment history, he indicated that he had worked in insurance for decades with great success until his knees impaired his mobility. That is appropriately considered in the TDIU section below. The Board finds that the depression, irritability, insomnia, fatigue, nightmares, flashbacks, and little motivation do not rise to the level of the criteria for a 70 percent rating. Absent any showing of the other criteria for a 70 percent evaluation, the evidence of a history of suicidal ideation in this case is insufficient to support such an evaluation, for accrued benefits purposes. See 38 C.F.R. § 4.126(a). Extraschedular Consideration The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). Turning to the first step of the extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the Veteran's service-connected PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested nightmares, irritability, insomnia, depressed mood, and social withdrawal. These symptoms are part of the schedular rating criteria. In addition, the level of occupational and social impairment is explicitly part of the schedular rating criteria. In addition, the GAF score is incorporated as part of the schedular rating criteria as it tended to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The Veteran does not have any symptoms from his service-connected PTSD that are unusual or are different from those contemplated by the schedular criteria during either the period before or on and after September 6, 2006. The available schedular evaluations for the service-connected disability are adequate to rate the disability. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96; Thun, 22 Vet. App. at 115. Additional Considerations Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The RO has assigned staged ratings during the course of this appeal. The Board finds that the evidence reflects that the disability level during the period prior to September 6, 2006, more closely approximated the criteria for a 30 percent evaluation than that for a 50 percent evaluation and that the evidence reflects that the disability level during the period on and after September 6, 2006, more closely approximated the criteria for a 50 percent evaluation than that for a 70 percent evaluation. See 38 C.F.R. § 4.7. Similarly, the Board finds that the assigned schedular evaluations both prior to and on and after September 6, 2006 were adequate to rate his PTSD during both stages and that referral for extraschedular consideration is not warranted for either stage or any portion of the appeal period. Given the facts in this case, the Board finds that the Veteran's depression was appropriately rated as 50 percent disabling, and no higher, for the entire initial rating period on appeal. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. As such, the Board finds that the preponderance of the evidence is against a higher initial rating appeal for PTSD for any period, for accrued benefits purposes. Consequently, the benefit-of-the-doubt rule does not apply, and the appeal must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. TDIU Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of a service-connected disabilities: Provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). Marginal employment, odd-job employment, and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. 38 C.F.R. § 4.17(a) (2012). Even where the minimum schedular criteria are met, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a). In reaching such a determination, the central inquiry is whether the Veteran's service-connected disabilities are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor that takes this case outside the norm. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran filed a variety of claims for service connection for knee, back, hemorrhoid, nervous condition, tinnitus, bilateral hearing loss, and scar disabilities in October 2003. His February 2011 formal claim for TDIU stated that he thought he was unemployable due to PTSD, osteoarthritis, and hemorrhoids, while his appeal continued from claims arising from the October 2003 filing. The Board infers that the Veteran also claimed TDIU with his October 2003 claims. See Comer v. Peake, 552 F.3d 1362, 1366 (Fed. Cir. 2009). The Board finds that, as of October 2003, the Veteran's service-connected combined for a rating of 60 percent, rendering him eligible for TDIU consideration under 38 C.F.R. § 4.16(a) (disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, and disabilities resulting from common etiology or a single accident may be considered as one disability for TDIU combined rating percentage eligibility). As of October 2003, the Veteran was service-connected for traumatic arthritis and laxity of each knee, with four 10 percent ratings assigned, degenerative disk narrowing at L5-S1 with prominent facet arthrosis, rated as 20 percent disabling, residuals of a shell fragment wound of the right upper arm, rated as ten percent disabling, scar residuals of shrapnel wounds of the back and right arm, rated as noncompensable, bilateral tinnitus rated as 10 percent disabling, and bilateral hearing loss, rated as noncompensable. Considering the bilateral factor for the four knee disabilities, the combined rating was 60 percent as of October 2003. The Veteran's service-connected disabilities of the low back, lower extremities and right arm, which were the result of multiple injuries incurred in action, have been combined to at least a 60 percent rating throughout the period on appeal from October 2, 2003. For the period from August 19, 2004, service connection for PTSD with a 30 percent rating was in effect, for a combined rating for all disabilities of 70 percent; for the period from March 7, 2005, with an increased rating to 20 percent for knee disability, the combined rating was 50 percent; and for the period from September 6, 2006, with a higher rating of 50 percent for PTSD for this period, the combined rating was 90 percent. The Veteran received increases in his combined disability rating with the grant of service connection for PTSD in August 2004, increased ratings for his knee osteoarthritis in March 2005, an increased rating for PTSD in September 2006, further increased ratings for his knee arthritis in February 2007, and a compensable rating for his shrapnel wound scar residuals in March 2009. Even considering the bilateral factor, his combined schedular evaluation did not reach 100 percent. The Board has also granted service connection for hemorrhoids above. Although the RO will assign an initial rating and effective date for the hemorrhoid disability, the Board notes that the maximum schedular rating for hemorrhoids is 20 percent. See 38 C.F.R. § 4.114, DC 7336 (2012). Even if the RO assigned a maximum schedular rating for the hemorrhoids, the Veteran would not receive a combined 100 percent schedular rating at any time period prior to his death; thus, the Board will proceed to consider TDIU eligibility under 38 C.F.R. § 4.16(a). Although the RO has not assigned an initial rating or effective date for the grant of service connection for a hemorrhoid disability, the Board notes that the standard for TDIU is distinct and separate from the standard for initial ratings. See 38 C.F.R. §§ 3.321, 3.340, 4.16 (2012). Also, in adjudicating the TDIU issue on appeal, the Board has considered any impact of hemorrhoids on employability using the evidence that is of record. Given his death, additional attempts to develop such evidence would be futile. The Board finds that all necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board finds that the Veteran was not unable to secure or follow a "substantially gainful employment" for any period. The Veteran's account of his earnings is not contradicted by any other evidence. Both of the annual income amounts are substantially above the U.S. Census Bureau's poverty thresholds for 2003 to 2011 for one person. See U.S. Department of Commerce, Bureau of the Census, Poverty Data, Poverty Threshold (http://www.census.gov/hhes/www/poverty/data/threshld.html). The Veteran described his employment history in February 2011. He had worked for a life insurance company from 1976 to January 2003, switched to another life insurance company in January 2003 where he remained until November 2010, and attempted to work for himself from November 2010 to February 2011. He also stated that his disability began affecting his full-time employment in January 1995, that he last worked full-time in December 2000 which is when he became to disabled to work, and that the most he ever earned in one year was $200,000, also in 2000. He listed the hours he worked per week as 40-65 prior to January 2003, with fifteen days lost from illness, 30-40 between January 2003 and November 2010, with 20+ days lost from illness, and 20-30 hours per week from November 2010 to February 2011, with 30+ days lost from illness. The Veteran reported diminished income of only $5,000 per month between 2003 and 2010, which is $60,000 on an annual basis, and $2,577 per month from November 2010 to February 2011, which is $31,000 on an annual basis. The Veteran lived with his wife and youngest child in these years. The youngest child appears to have moved out by the time of the August 2010 VA examination for PTSD, discussed above, though the exact date is not clear from the record. Based on this evidence, the Board finds that the Veteran had substantially gainful employment, despite his disabilities and time lost due to illness. The Veteran's statements were to the effect that he could no longer work in the insurance sales industry and that he had been unable to find new employment in that industry. His statements are not directly on point. The standard of unemployability is broader than whether the Veteran was able to remain in his chosen profession. He did not present evidence that he was unemployable for any substantially gainful profession, but that he was unemployable for his chosen profession. An employer submitted January and February 2006 statements in support of the Veteran's claims. The January 2006 statement indicates that the co-worker had experienced deterioration in his physical ability to perform the regular duties of his occupation due to his osteoarthritic condition. The Veteran had been attempting to serve his existing clients by phone. The February 2006 statement indicates that the Veteran's osteoarthritic condition and lack of mobility had greatly reduced the Veteran's income. The Veteran's employer submitted a July 2010 letter that the Veteran's physical disabilities and worsening attention span had diminished his ability to secure sales of new clients to a point of non-productivity. Up until ten to twelve years before, the Veteran had been one of the top agents with the firm and had once been named the leading Annuity and Insurance Salesperson nationwide for the year by a respected insurance company. Although his performance had deteriorated, the Veteran had been allowed to maintain his relationship with the firm, but the employer indicated that, if terminated, the Veteran would have little chance of finding new, gainful employment in the insurance industry. The Veteran underwent numerous examinations for his service-connected disabilities that reflect occupational impairment caused by each disability. Even considering the multiple service-connected disabilities, and fully recognizing the occupational impairment caused by them, the evidence shows that the Veteran was not unable to secure or follow a "substantially gainful employment" for any period. The Veteran's uncontradicted account of his earnings reflects that the annual income amounts are substantially above the U.S. Census Bureau's poverty thresholds for 2003 to 2011 for one person. See U.S. Department of Commerce, Bureau of the Census, Poverty Data, Poverty Threshold (http://www.census.gov/hhes/www/poverty/data/threshld.html). For these reasons, the Board finds that the requirements for a TDIU have not been met. In reaching these conclusions, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the TDIU claim, that doctrine is not applicable. See 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a hemorrhoid disability is granted. An initial rating for PTSD, in excess of 30 percent prior to September 6, 2006, and in excess of 50 percent on and after September 6, 2006, is denied. A TDIU is denied. ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs