Citation Nr: 1319255 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 07-27 364 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period from August 1, 2007 through April 9, 2009. 2. Entitlement to a disability evaluation in excess of 70 percent for PTSD from April 10, 2009. 3. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD David S. Nelson, Counsel INTRODUCTION The Veteran had active military service from January 1969 to October 1970 and from December 1970 to June 1975. This case comes to the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously before the Board in September 2010 and was remanded for additional development. In May 2012 VA medical records dated in March 2012 and available through the Compensation and Pension Records Interchange (CAPRI) were uploaded to the Veteran's electronic Virtual VA folder. The records are not pertinent to the matters on appeal and remand for review and consideration by the AOJ is not required. 38 C.F.R. §§ 19.37(b), 20.1304(a) (2012). In the May 2013 "Appellate Brief Presentation" the Veteran's accredited representative raised the issue of entitlement to TDIU as part and parcel of the PTSD increased rating claim on appeal, particularly in view of the current combined total rating of 90 percent in conjunction with the Veteran's continuing unemployment. Although the TDIU claim has not been adjudicated by the Agency of Original Jurisdiction (AOJ), it is an issue set forth on appeal because it is part and parcel of the claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. For the period from August 1, 2007 through April 9, 2009, the Veteran's PTSD did not cause occupational and social impairment with deficiencies in most areas. 2. For the period from April 10, 2009, the Veteran's PTSD did not cause total occupational and social impairment. 3. The Veteran is service-connected for PTSD, rated as 70 percent disabling; coronary artery disease (CAD), rated as 60 percent disabling; residuals of a gunshot wound to the abdomen, rated as 30 percent disabling, and painful scars associated with cholecystectomy, rated as 20 percent disabling; the combined service-connected disability rating is 90 percent. 4. The Veteran is precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent for PTSD for the period from August 1, 2007 through April 9, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 70 percent for PTSD from April 10, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for entitlement to a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Duty to Notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). By correspondence dated in April 2007, April 2011, and June 2011 the Veteran was informed of the evidence and information necessary to substantiate the PTSD claim, the information required to enable VA to obtain evidence in support of the claim, the assistance that VA would provide to obtain evidence and information in support of the claim, and the evidence that should be submitted if there was no desire for VA to obtain such evidence. 38 U.S.C. § 5103(a). The Veteran has been informed of the need for evidence demonstrating an increase in the severity of his disability and the effect that his service-connected disability has on his employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). In the April 2007 letter the Veteran received notice regarding the assignment of a disability rating and/or effective date in the event of an award of VA benefits. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice was completed prior to the initial AOJ adjudication of the claim. Pelegrini. Importantly, the Board notes that the Veteran is represented in this appeal. Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted argument in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of the increased rating claim such that the essential fairness of the adjudication is not affected. Duty to Assist The Veteran's service treatment records are associated with the claims file, as are private medical records. Identified VA medical records are associated with the physical claims file and the Veteran's Virtual VA file. Records from the Social Security Administration (SSA) are also of record. The Veteran has undergone VA examinations that addressed the medical matters presented on the merits by this appeal. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as they included an examination of the Veteran and elicited his subjective complaints. The VA examinations described the Veteran's PTSD symptoms in sufficient detail so that the Board is able to fully evaluate the claimed disability. As such, the Board finds that VA's duty to assist in obtaining a VA examination has been met. The Board finds that there has been substantial compliance with its September 2010 remand instructions. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Veteran has not referenced any other pertinent, obtainable evidence that remains outstanding. VA's duties to notify and assist are met, and the Board will address the merits of the claims. Legal Criteria Disability evaluations are determined by comparing a veteran's present symptoms with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Staged ratings are appropriate for increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Diagnostic Code 9411 addresses PTSD. Under that code, a 50 percent rating is appropriate when there is 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating for PTSD is provided for 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. A 100 percent rating for PTSD is provided for 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. §§ 4.125-4.130. The above symptoms 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, 443 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect his level of occupational or social impairment. Id. at 443; 38 C.F.R. § 4.126. A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Richard v. Brown, 9 Vet. App. 266 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994)). GAF scores ranging from 61 to 70 reflect 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores from 51 to 60 are indicative of moderate 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). GAF scores from 41 to 50 reflect serious 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). Scores from 31 to 40 indicate impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the VA disability rating assigned. See 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 31, 1995). It should be noted that use of terminology such as "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, also is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a percentage disability rating. 38 C.F.R. §§ 4.2, 4.6, 4.126. Factual Background A February 2005 rating decision granted the Veteran service connection for PTSD and assigned a 30 percent rating, effective December 1, 1998. A rating decision dated in March 2006 increased the rating for PTSD to 50 percent, effective September 9, 2005. The Veteran's claim for an increased rating for his service-connected PTSD was received in March 2007. A June 2007 rating decision continued the 50 percent rating for PTSD. Following the Veteran's timely appeal, a September 2010 Board decision denied a rating in excess of 50 percent for PTSD for the period from March 27, 2006 through July 31, 2007, and remanded the issue of entitlement to a disability evaluation in excess of 50 percent for PTSD for the period beginning August 1, 2007. A January 2012 rating decision increased the rating for PTSD to 70 percent, effective from April 10, 2009. Based on the foregoing, the issues before the Board are entitlement to a disability evaluation in excess of 50 percent for PTSD for the period from August 1, 2007 through April 9, 2009, and entitlement to a disability evaluation in excess of 70 percent for PTSD from April 10, 2009. Before undertaking analysis, it is notable that the Veteran is service-connected for PTSD but not for such disorders as anxiety and depression, which also have been diagnosed. The Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181 (1998). As such, the Board shall consider all psychiatric symptomatology to be attributable to depression. Doing so results in no prejudice to the Veteran since it means that the evidence in its entirety will be reviewed. I. Entitlement to a disability evaluation in excess of 50 percent for PTSD for the period from August 1, 2007 through April 9, 2009. The evidence for this time period includes an August 2007 statement from the Veteran indicating that his PTSD medications had been increased. In a March 2008 statement the Veteran noted that his medicine (Bupropion HCL) had been increased from 75 mg to 150 mg twice a day. In a December 2007 VA record the Veteran noted that he had recently had problems with short term memory and feared that he was developing Alzheimer's disease. August 2007, October 2007, November 2007, January 2008, February 2008 and March 2008 VA social work notes indicated that the Veteran denied suicide and homicide ideation. The Veteran was neatly dressed and groomed, and his mood and affect were appropriate to the situation. A September 2007 VA record noted that the Veteran complained of feeling terrible as a result of a loss of weight and appetite, lethargy, and weakness. An August 2007 VA record noted that the Veteran complained that sometimes he would wake up angry. While he stated that issues with his ex-wife had been resolved, he was often moody or angry with his mother or girlfriend "for no good reason." Mental status evaluation revealed that the Veteran's insight, judgment, and concentration were good; the Veteran's mood was animated and there was no memory impairment. There were no hallucinations, delusions, or suicidal/homicidal ideations. The assessment included prolonged PTSD. The Veteran was characterized as "doing fairly well." As for his employment from August 1, 2007 through April 9, 2009, the Veteran offered little in the way of "updates" from his May 2007 VA examination comments wherein he indicated that his usual occupation involved manual labor but that he had been unemployed for 5 to 10 years due to medical disability rather than the effects of his PTSD. The Board finds that the Veteran does not warrant a disability evaluation in excess of 50 percent for his PTSD for the period from August 1, 2007 through April 9, 2009. Numerous symptoms listed in Diagnostic Code 9411 for a 70 percent rating were not met during this period. In this regard, there is no evidence that the Veteran neglected his personal appearance and hygiene. Instead, the Veteran was described as neatly dressed and groomed. There also is no evidence that his speech was intermittently illogical, obscure, or irrelevant. Further, there is no showing of obsessional rituals which interfere with routine activities, and, in the same manner, no panic attacks have been demonstrated during this period. The Board therefore finds that the evidence does not show near-continuous panic affecting the ability to function independently, appropriately, and effectively. While some references to suicide ideation are associated with the Veteran's older treatment records, the Veteran has denied current suicidal ideation or thoughts during this time period. The Board acknowledges that there is some evidence that the Veteran manifested a few of the symptoms listed in Diagnostic Code 9411 for a 70 percent disability rating from for the period from August 1, 2007 through April 9, 2009. Clearly the Veteran has indicated that he has essentially felt depressed at times. Even, however, were this to be considered near-continuous depression, there is no evidence that such depression affected his ability to function independently, appropriately, and effectively. In this regard, no problems with activities of daily living were found in the treatment records. Also, records also repeatedly reflect that he was acting appropriate to this situation. While the Veteran noted some memory problems in one record, such was not noted in any of the multiple social work counseling notes, and a August 2007 record noted that the Veteran's concentration was good, with no memory impairment. At any rate, as impairment of short and long term memory is one of the symptoms listed in Diagnostic Code 9411 for a 50 percent disability rating, such has already been recognized by the RO. The evidence further contains the Veteran's complaints involving difficulties with his girlfriend and mother, thus indicating some evidence that the Veteran had difficulty adapting to stressful circumstances. However, the Board notes that the Veteran reported that he was able to resolve some difficulties with his ex-wife, thus leading the Board to the conclusion that an "inability" to establish and maintain any effective relationships is not shown. While the evidence for this time period is not abundant, the evidence of record tends to reflect moderate levels of PTSD symptoms, and a review of the clinical findings from the psychiatric records do not reveal symptoms which more closely approximate the criteria for a rating of 70 percent. As such, a disability evaluation in excess of 50 percent for PTSD for the period from August 1, 2007 through April 9, 2009 is not warranted. II. Entitlement to a disability evaluation in excess of 70 percent for PTSD from April 10, 2009. Private medical records for heart disability dated from May 2009 through April 2010 noted that the Veteran was oriented to time, place, and person. An April 10, 2009 VA record noted that the Veteran was grieving over the death of a cousin who had been like a brother to him. He had become irritable and angry, and had recently struck his girlfriend, which he had felt bad over. The Veteran reported that he was extremely upset and had lost interest in many activities. A positive depression screen was noted. It was recommended that he receive follow-up in two weeks for bereavement. An April 30, 2009 record noted that the Veteran was doing better taking Buspar, Fluoxetine, and Buproprion. He was still getting over his close friend's death and expressed fear concerning the level of violence in his own community. An April 13, 2011 VA cardiology record noted that the Veteran was having conflicts with friends and associates. It was requested that the Veteran receive individual therapy for his PTSD. An April 2011 record noted that the Veteran had recently had suicidal ideation. He reported family members as protective factors. He also reported mood improvement with his medications. A GAF of 45 was noted, along with a diagnosis of depression/PTSD. The Veteran was alert, cooperative, and appropriately groomed. Speech was unremarkable, and the mood was anxious and depressed. Thoughts were circumstantial and the Veteran reported suicidal ideations of a passive nature and also reported visual hallucinations. His insight was marginal and his judgment was impaired. He reported that he had some friends but little in the way of interests or hobbies. At an April 2011 VA PTSD examination, the Veteran's symptoms included anxiety, suspiciousness, sleep impairment, impaired abstract thinking, suicidal ideation, and an inability to establish and maintain effective relationships. It was noted that on the examination itself the Veteran denied any suicidal ideation. The examiner characterized the Veteran's PTSD as being productive of occupational and social impairment with reduced reliability and productivity. It was noted that the Veteran's PTSD impacted his ability to work. The diagnosis was PTSD and a GAF of 55. A May 2011 VA record indicates that the Veteran was "hanging on" and denied any suicidal or homicidal intent but did worry about this future. He had recently hit a child with his car; while the child was okay, the event proved unsettling and caused him to think of his grandchildren. The Veteran complained of sleeping problems and was disheveled in appearance and had not bathed in some time. PTSD symptoms included intrusive thoughts, nightmares, irritability, and social isolation. A GAF of 45 was reported. A June 2011 VA record noted that the Veteran denied decreased energy, concentration, and any change in appetite or sleep. He denied suicidal or homicidal ideations and also denied visual or auditory hallucinations. The Board finds that an evaluation higher than 70 percent is not warranted for PTSD for the period on appeal from April 10, 2009. The criteria for the next highest and maximum evaluation of 100 percent have not been met. It is acknowledged, like above, that the Veteran's symptoms cause occupational and social impairment. Yet this impairment is not total. The Veteran's symptoms do not include any of those noted to cause total impairment. Specifically, his thought processes and ability to communicate (speech) both have not evidenced any gross impairment. While one report of visual hallucinations and suicidal ideation were noted, such reports have been the exception, and the Veteran has otherwise been fully oriented. He has had no problems with performing activities of daily living, including maintaining minimum personal hygiene. The Veteran has often discussed relatives or acquaintances, thus revealing that total social isolation has not been shown. Nothing approaching memory loss of names of relatives has been shown or even asserted. Total occupational and social impairment other than from the above symptoms further does not exist. He maintains contacts with family members. Gross problems in numerous areas, which would be expected if there were total occupational and social impairment, do not exist. In this regard, GAF scores of 45-55 have been assigned. These scores, while characteristic of serious symptoms, do tend to convey occupational and social impairment of substantially less severity than total. Therefore, a rating in excess of 70 percent for PTSD from April 10, 2009 is not warranted. Conclusion to PTSD rating claims In adjudicating a claim the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences concerning his PTSD. See Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of his PTSD according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings directly address the criteria under which the Veteran's PTSD is evaluated. As such, the Board finds these records to be the most probative evidence with regard to whether an increased rating is warranted. The Board has been mindful of the "benefit-of-the-doubt" rule, but, in this case, there is not such an approximate balance of the positive evidence and the negative evidence to permit more favorable determinations. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As for extraschedular consideration, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Court clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If so, then the assigned schedular evaluation is adequate, referral for extra-schedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation fails to reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment or frequent periods of hospitalization. Id. At 116. If additional factors are found, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether justice requires assignment of an extra-schedular rating. Id. The evidence of record does not reveal that the Veteran's PTSD is so unusual or exceptional in nature as to render his schedular rating inadequate. The Veteran's disability on appeal has been evaluated under the applicable Diagnostic Code that has specifically contemplated the level of occupational and social impairment caused by service-connected PTSD. The Veteran's symptoms such as sleep difficulties, anger, and difficulty in establishing effective relationships are specifically enumerated under the applicable Diagnostic Codes. Therefore, referral for assignment of an extra-schedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). III. TDIU Although the TDIU claim has not been adjudicated by the Agency of Original Jurisdiction (AOJ), it is an issue set forth on appeal because it is part and parcel of the claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In light of the favorable decision to grant TDIU, any deficiency as to VA's duties to notify and assist pursuant to the provisions of the Veterans Claims Assistance Act of 2000 (VCAA) as to the TDIU claim is rendered moot. The Veteran is service-connected for PTSD, rated as 70 percent disabling; coronary artery disease (CAD), rated as 60 percent disabling; residuals of a gunshot wound to the abdomen, rated as 30 percent disabling, and painful scars associated with cholecystectomy, rated as 20 percent disabling; the combined service-connected disability rating is 90 percent. Entitlement to a TDIU requires evidence of service-connected disability so severe that it is impossible for the veteran in particular, or an average person in general, to follow a substantially gainful occupation. 38 U.S.C.A. § 1155;38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations indicate that when a veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned when: 1) if there is only one disability, this disability shall be ratable at 60 percent or more; and 2) if there are two or more disabilities, at least one disability shall be ratable at 40 percent or more, and there must be sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In addition to the foregoing, there must be evidence that the disabled person is unable to secure or follow a substantially gainful occupation. Id. Marginal employment is not considered substantially gainful employment. Id. A total disability rating may also be assigned pursuant to the procedures set forth in 38 C.F.R. § 4.16(b) for veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). As the Veteran has disability (PTSD and CAD) ratable at 40 percent or more, to bring the combined rating to 70 percent or more (the Veteran's combined service-connected disability rating is 90 percent), he does satisfy the percentage rating standards for individual unemployability benefits. The question now becomes whether the Veteran is precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected disabilities. SSA records dated in November 1996 indicate that the Veteran has a high school equivalency degree (although he has elsewhere indicated he had one year of college) with most of his employment experience involving working as a machine operator in a manufacturing facility. He had not engaged in substantial employment since August 1994. The Veteran was awarded SSA disability benefits primarily for back disability and, at least in part, for symptoms related to depression. As for the Veteran's heart disability in general, records show coronary artery disease diagnosed in 2006, with a history of two stent placements. January 2006 testing showed a (metabolic equivalent) METS of 7, and ejection fraction of 53 percent. An EKG from April 2010 showed evidence of cardiac hypertrophy, and a heart cauterization performed in March 2010 showed ejection fraction was 50 percent. Records reveal that the Veteran has been taking about 5 different medications for his heart disability on a daily basis. An April 2011 VA medical record noted that the Veteran had chest pain that had awakened him in the middle of the night. As noted, in May 2007 the Veteran indicated that his usual occupation involved manual labor but that he had been unemployed for 5 to 10 years prior. While the Board has not found that the Veteran's PTSD, by itself, results in total occupational impairment, the occupational impairment from PTSD is nonetheless significant. This is shown by the Veteran's receipt of a 45 GAF, indicative of serious impairment in his occupational functioning. At the bare minimum, the Veteran's PTSD symptoms such as anxiety, impaired abstract thinking, and irritability, coupled with the obvious physical limitations placed on the Veteran by his heart disability, leads the Board to find that the evidence of record as a whole reveals that the Veteran is precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected disabilities. Resolving doubt in the Veteran's favor, the Board finds that entitlement to a TDIU is warranted. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A disability evaluation in excess of 50 percent for PTSD for the period from August 1, 2007 through April 9, 2009 is denied. A disability evaluation in excess of 70 percent for PTSD from April 10, 2009 is denied. Entitlement to a TDIU is granted, subject to the regulations applicable to the payment of monetary benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs