Citation Nr: 1319361 Decision Date: 06/14/13 Archive Date: 06/21/13 DOCKET NO. 10-40 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent prior to November 2, 2011, for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating for individual unemployability prior to November 2, 2011. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran served on active duty from March 1968 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In February 2011, more than one year after the issuance of the January 2010 rating decision awarding service connection for PTSD, the Veteran filed a statement which the Board interprets as a claim of entitlement to an earlier effective date for the award of service connection for PTSD. The claim has not been adjudicated by the Agency of Original Jurisdiction. Therefore, the Board does not have jurisdiction over it and it is referred for appropriate action. FINDINGS OF FACT 1. Prior to November 2, 2011, the Veteran's PTSD results in impairment approximating deficiencies in most areas but not total impairment. 2. Prior to November 2, 2011, the Veteran has a rating of 70 percent, and the evidence suggests that the service-connected psychiatric disability is of such nature and severity as to prevent the Veteran from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to November 2, 2011, the criteria for a rating of 70 percent, but no higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9400 (2012). 2. The criteria for a TDIU prior to November 2, 2011, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Service connection was established for PTSD in a January 2010 decision. The Veteran appealed the initial rating assigned, contending that a higher rating was warranted. In a September 2012 rating decision, a 100 percent rating was assigned, effective November 2, 2011. The Veteran maintained his appeal, contending that a total rating is warranted for PTSD prior to November 2, 2011. The Veteran has also indicated that he is unemployed and has submitted evidence of unemployability due to PTSD, and the Board finds the record raises the issue of entitlement to a TDIU prior to November 2, 2011. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §§ 4.7, 4.14. In an appeal of an initial rating (such as in this case), consideration must be given to "staged" ratings, i.e. disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board will thus consider entitlement to "staged ratings." Under the rating criteria for mental disorders, a 50 percent rating is assigned for 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. A 70 percent rating is assigned 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); and the inability to establish and maintain effective relationships. A 100 percent rating is assigned when PTSD causes 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. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Without those factors, however, differentiating a 30 percent evaluation from a 50 percent evaluation would be difficult. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. See also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). The record reflects the Veteran and his spouse's endorsement of symptoms including nightmares, intrusive memories, flashbacks, irritability, and social withdrawal. The Veteran's spouse has also reported that the Veteran's irritability and isolation has caused their child to become distressed and withdrawn from family activities. A September 2006 VA treatment record reveals that the Veteran was alert and oriented. A November 2006 VA treatment record reflects the Veteran's history of smoking marijuana prior to the evaluation. The examining psychologist noted that the evaluation was cut short, though "enough information regarding [the Veteran's] symptoms was collected." The psychologist noted that it was difficult to determine if the Veteran's current symptoms were the result of the Veteran's use of marijuana or a separate psychiatric condition. The psychologist added that "all information obtained from this interview should be interpreted with caution due to [the Veteran] having used drugs (and report of being high) during the interview." The record reflects the Veteran's histories of frequent nightmares, intrusive images and memories, distress at cues, detachment and numbing, sleep difficulty, and hypervigilance, which the Veteran indicated had negatively impacted his romantic relationships and ability to work. The Veteran reported that he often felt depressed and had little enjoyment in life and admitted to intermittent suicidal ideation with no history of suicidal behavior. The Veteran further reported that he sometimes heard his name called when there was no one around. However, the psychologist found it difficult to determine if the auditory hallucination was related to use of marijuana, as the Veteran reported always being high, or to a separate psychiatric diagnosis. Examination revealed that the Veteran was intermittently engaged in the interview, although relatively alert and conscious. He appeared groomed and clean. The Veteran made inconsistent eye contact and avoided answering questions. Speech was slow at times, and the Veteran became tearful and noticeably upset when asked to discuss his traumatic experiences in Vietnam. Mood was difficult to assess due to marijuana use, though the Veteran appeared depressed. Affect was slow. The Veteran was hyper at first and then relaxed. Thought process was goal-directed. The Veteran repeatedly referred to his claim throughout the interview, even after being informed that the interview was for treatment. He denied suicidal plan or intent but reported fleeting thoughts of jumping off his balcony or a moving subway. He denied homicidal intent or plan. Insight and judgment were poor. Concentration and attention were difficult to assess because of use of marijuana. The psychologist diagnosed cannabis dependence, rule out PTSD, rule out depressive disorder, and rule out cannabis induced mood disorder. The examiner explained that the Veteran reported symptoms consistent with a diagnosis of PTSD but it was difficult to piece apart the symptom related to PTSD and the symptoms due to chronic daily use of marijuana. The psychologist assigned a global assessment of functioning (GAF) score of 47. A March 2007 VA treatment record reflects the Veteran's history of "times when he is very nervous," sleep disturbance, irritability, feelings of unsafeness, nightmares, depression, periods of feeling hopeless, flashbacks, paranoia, and passive suicidal ideation without plan or intent. He reported "okay" energy, appetite, and concentration and indicated that he enjoyed being with his family. Examination revealed euthymic mood and affect congruent with mood. There was no perceptual disturbance. Thought process and association were normal and coherent, and there was no unusual thought content. Speech was normal in rate and rhythm, and language was intact. He was alert and oriented to person, place, and time, and memory and attention span and concentration were intact. The Veteran was diagnosed with PTSD, dysthymia, cannabis abuse, and antisocial disorder, and a GAF score of 52 was assigned. An August 2007 VA treatment record reflects the Veteran's history of difficult, intrusive recollections of Vietnam while visiting Panama. The Veteran reported that he was "so disturbed being there that he saw a psychiatrist," who advised him to continue taking his medication. He reported that he ran out of medication while there but restarted when he returned home and was "starting to feel better." Examination revealed that the Veteran was pleasant, cooperative, and neatly groomed. Speech was clear and normal. Mood was "okay." Affect was slightly anxious. Thoughts were organized and goal-directed, and the Veteran denied hallucinations, suicidal ideation, or homicidal ideation. He reported using less marijuana. He was assessed with PTSD and marijuana abuse and assigned a GAF score of 52. September 2007 VA treatment records indicate that the Veteran was "close with his wife and daughter" but "somewhat distant with other family," "ha[d] few friends, and [wa]s somewhat isolated." The records indicate that the Veteran was admitted into a PTSD outpatient treatment program. An October 2007 Vet Center assessment report reveals that the Veteran was first seen in March 2007, at which time he expressed concern of "losing it and of ongoing fears and thoughts of him losing control of his emotions." The record notes that the Veteran presented depressed, exhibited poor insight and judgment, was suspicious, displayed some alertness, mentioned feelings of detachment, and indicated intrusive thoughts and nightmares. The report notes that the Veteran "appeared struggling with feelings of survivor's guilt resulting in self-punishing (destructive) behavior" and "described deficits in sleep and concentration." The Veteran was also noted to have issues with authority figures and cynicism and mistrust for the government. The examining therapist reported that the Veteran remained detached and socially isolated and had issues with impulsivity, poor concentration, preoccupation, and attention deficits. The therapist reported that the Veteran had spoken about jumping off his balcony and that when asked about the "imminentness and actual intention of suicidality, his response [was] that he could be locked up for answering a specific way." The therapist added that the Veteran's personal hygiene worsened over the counseling period, that his blunt flat affect made him somewhat unapproachable, that the Veteran remained depressed most of the day, and that the Veteran's propensity to hurt or harm others was becoming more apparent. The therapist diagnosed severe PTSD, major depressive disorder, and rule out adult antisocial compartment and assigned a GAF score of 43. An October 2007 VA treatment record reflects the Veteran's history of frequent nightmares, poor sleep, hypervigilance, depression, social withdrawal, anxiety, intrusive memories, irritability, and poor frustration tolerance. He reported smoking marijuana "at times." Examination revealed coherent speech and depressed and anxious mood. The Veteran was oriented to time, place, and person. Concentration and attention span were impaired, and retention and recent memory were defective. The Veteran was diagnosed with PTSD and assigned a GAF of 45. Additional October 2007 and November 2007 VA treatment records indicate that the Veteran denied suicidal or homicidal ideation. A January 2008 VA treatment record indicates that the Veteran was being discharged from the PTSD outpatient treatment record. The record notes that the Veteran initially attended with some regularity but stopped attending as the holiday season approached. The record indicates that a discharge GAF score of 45 was assigned. An April 2009 VA treatment record indicates that the Veteran "seem[ed] very depressed" but denied a plan to commit suicide. The record notes that the Veteran was concerned that his job search had not paid off and upset that he was being asked to pay the rent on an apartment he was not using. A July 2009 VA treatment record reveals that the Veteran was neatly groomed and casually dressed. Mood was dysthymic, and affect was congruent to mood. The Veteran denied suicidal or homicidal ideation. The Veteran also denied regular use of marijuana, indicating that he had stopped using it regularly some time the previous year. The Veteran reported symptoms including sleep disturbance, intrusive thoughts, and flashbacks. The record indicates that the flashbacks were associated with symptoms of panic. The Veteran denied nightmares because he "can feel one coming on and wakes up." The Veteran indicated that he did not socialize with others because was "very moody" and was "afraid he might 'snap' at someone." He also reported feeling very guarded and unsafe when in a crowded place. He indicated that there were times when he felt "very easily angered and depressed" and he separated himself from his family because he worried he might hurt someone. Examination revealed appropriate eye contact, logical and goal-directed thought process, and fair judgment and insight. The Veteran was oriented to time, place, and person. A GAF score of 45 was assigned. A November 2009 VA treatment record indicates that the Veteran was seeking medical help because he was under great stress due to financial and family problems. A follow-up treatment record reflects the Veteran's history of stress dealing with his landlord and VA. He denied suicidal ideation, explaining that he did not want to hurt his family. Examination revealed that the Veteran was alert, calm, and fully oriented with no hallucination, paranoid delusion, or suicidal or homicidal ideation, intent, or plan. Affect was appropriate, and mood was anxious. Cognition was grossly intact, and judgment and insight were fair. The Veteran was assigned a GAF score of 50. A December 2009 VA treatment record reflects the Veteran's history of improved mood because his wife had made progress with immigration status. The record notes that the Veteran was neatly dressed and calmer than the previous visit in November 2009. A subsequent December 2009 VA treatment record indicates that the Veteran related well, was well-oriented to time, place, and person, and had no suicidal or homicidal ideation or thought disorder. The psychiatrist noted that the Veteran's mood was euthymic, though with palpable anxiety. A January 2010 VA treatment record reflects the Veteran's history of poor sleep, nightmares, depression, hyperalertness, and a "very bad temper." He also reported continued use of marijuana. He indicated that he was having problems with his landlord. The examining social worker noted that the Veteran was neatly and casually dressed and that the Veteran answered questions in a coherent manner but would lose focus "at times." A February 2010 statement from a VA psychiatrist reports a finding that the Veteran's PTSD was manifested by nightmares, daytime intrusions, hyperreactivity, depressed mood, anxiety and insomnia and that the Veteran had not worked since approximately 1984 as a result of difficulties relating to his symptoms. See Stein statement. A February 2010 statement from a social worker reflects a finding of PTSD with severe symptoms "such as lack of sleep, irritability, outburst of anger, difficulty concentrating, and hypervigilence." The statement reflects the Veteran's histories of difficulty socializing with his family and members of the community, avoidance of crowds, and nightmares and history. The record further reflects the Veteran's history that his psychiatric symptoms, and associated substance abuse, had put a strain on his marriage. The social worker noted that the Veteran had expressed suicidal ideation and had been unable to obtain employment or enjoy any type of normalcy with his family. An April 2010 VA examination record reveals the Veteran's history of depressed and anxious mood. He denied current suicidal or homicidal ideation but reported calling the suicide hotline a few months earlier because he had a gun and was going to shoot himself. He reported significant symptoms of PTSD including nightmares, intrusive thoughts, reexperiencing events, increased arousal, hypervigilance, anger, and irritability. He also reported being easily frustrated and having diminished interest and social isolation. He indicated that he had cut down on his marijuana use, though he reported increased drinking of alcohol. He reported that he was married but indicated that he had conflicts with his wife because she did not understand what he was going through and did not trust him. Examination revealed that the Veteran was appropriate groomed and casually dressed. His ability to maintain personal hygiene and perform activities of daily living was intact. He was alert and oriented to time, place, and person. Speech was normal, and there was no evidence of hallucination or delusion, suicidal or homicidal ideation, or motor abnormality. Mood was somewhat anxious with congruent affect that was somewhat constricted. Thought process was linear and goal-directed. The examiner diagnosed PTSD with significant symptoms of depression and anxiety. The examiner determined that the symptoms had "significantly negatively impacted [the Veteran's] social functioning, interpersonal relationships, and leisure and recreation activities" and assigned a GAF score of 45. An April 2010 VA treatment record, dating one day after the examination, reflects the Veteran's history of attempting suicide one month earlier. He explained that he was under stress dealing with his landlord and put a gun to his throat. He reported that he changed his mind and turned the gun into the city. He denied any current suicidal ideation, plan, or intent. An August 2010 VA treatment record reflects the Veteran's history that his family had to leave their previous apartment the end of July. The record notes that the Veteran had a strong family relationship and posed no risk to himself and indicates that the Veteran denied suicidal or homicidal ideation in the previous 30 days, though he did report suicidal ideation in the previous 60 days. He reported feeling depressed and anxious and having hallucinations and trouble understanding, concentrating, and remembering in the previous 30 days. The Veteran was assessed with PTSD, rule out psychosis, rule out depression with psychotic features vs. substance-induced mood disorder with psychotic features, and cannabis abuse vs. dependence and assigned a GAF score of 60. A February 2011 VA treatment record reflects the Veteran's history of a strong family relationship, and the record notes that the Veteran's spouse was supportive and seemed like a "strength for him." A GAF score of 52 was assigned. An April 2011 VA treatment record reflects the Veteran's history of intrusive memories, hypervigliance, nightmares, avoidance of crowds, and irritability. The Veteran indicated that he was working on improving his irritability and avoidance. He denied depression. He reported that things were "fair" with his family and indicated that he stayed busy going to the gym, going to appointments, and spending time with his daughter. Examination revealed normal speech, full affect, "ok mood," no suicidal ideation, no homicidal ideation, and fair insight and judgment. A GAF score of 60 was assigned. A June 2011 VA treatment record reflects the Veteran's history that his symptoms remained the same. An August 2011 VA treatment record reflects the Veteran's history of maintaining a "good" relationship with his children and a relationship with his brothers. Increased Rating for PTSD The Board has determined that a 70 percent rating is warranted for the period of the claim prior to November 2, 2011. The Board acknowledges that the record does not include a specific finding of deficiencies in most areas prior to November 2, 2011. The record does include evidence of depression, anxiety, social withdrawal, significant irritability, and suicidal ideation, and the assignment of GAF scores predominantly corresponding to serious symptoms or serious impairment prior to that time, however, and the Board finds the evidence indicates that the Veteran experienced exacerbations of his psychiatric symptoms with periods of increased stress. In light of this evidence, and giving the Veteran the benefit of the doubt, the Board finds the Veteran's symptoms most nearly approximate the disability picture contemplated by the 70 percent rating. A rating in excess of 70 percent is not warranted. The records contain no findings of total social or occupational impairment during this period, and the assigned GAF scores indicate findings of less than total impairment. The Board acknowledges that February 2010 statements from a VA psychiatrist and social worker note that the Veteran "had not" worked or "had been unable to" work. Neither the psychiatrist nor the social worker made a specific finding as to the Veteran's employability, however, and the statements appear to be recitations of the Veteran's history of not working. Moreover, even if the statements were interpreted as findings of total occupational impairment, the record is absent any finding of total social impairment, and the record consistently documents that the Veteran is able to maintain functional relationships with his family, which indicates that he does not have total social impairment. Furthermore, the reported symptoms and associated impairment do not approximate the disability picture created by the 100 percent rating. There is no medical evidence of gross impairment in thought processes, communication, or memory; loss of contact with reality, to include due to delusion or hallucination; grossly inappropriate behavior; total isolation; danger of hurting others; or disorientation. The Board acknowledges that the Veteran has reported suicidal thoughts. The record indicates that these thoughts are not constant, however, and the Veteran has predominantly denied any intent or plan. Thus, the Board finds the evidence does not suggest the existence of persistent suicidal ideation or risk of harm to self. The Board further acknowledges that the Veteran receives help from his spouse in performing his activities of daily living and that the record includes a finding of diminished hygiene. The record predominantly reflects findings of normal hygiene and grooming, however, and suggests that the Veteran's spouse provides help with activities limited as a result of stroke rather than PTSD. See, e.g., September 2007 VA treatment record. Thus, the Board finds the PTSD does not result in inability to perform activities of daily living due to PTSD. In sum, although the evidence dated prior to November 2, 2011, demonstrates impairment in functioning due to PTSD, it does not suggest that the impairment is total. The Board acknowledges that the November 2011 VA examiner found the Veteran had total impairment due to PTSD. The November 2011 VA examination record reports symptoms and findings drastically different from those presented in the evidence dated prior to November 2, 2011, however, to include findings of panic attacks at least weekly; gross impairment in thought processes or communication; memory loss such as forgetting names directions, or recent events; inability to maintain relationships; grossly inappropriate behavior; impaired impulse control; and neglect of personal appearance and hygiene. The evidence dated during the appellate period, which includes VA treatment record dated in August 2011, indicates that the Veteran maintained relationships with his family, was irritable but demonstrated appropriate behavior and impulse control, and had appropriate hygiene and appearance and contains no evidence of gross impairment in thought process, communication, or memory loss. As such, the Board finds the 2011 VA examiner's findings do not support a total rating prior to the date of that exam. Thus, a total schedular rating is denied. The Board has considered whether extraschedular consideration is warranted based on the evidence of occupational impairment secondary to the PTSD. See Barringer v. Peake, 22 Vet. App. 242 (2008). The Veteran's PTSD is manifested by impairment in functioning but those impairments are contemplated by the applicable rating criteria, and a higher rating is available for more severe symptomatology. Thus, the schedular rating criteria adequately contemplate the Veteran's PTSD related symptoms, and referral for an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU The Veteran has not worked at any time during the appellate period. He has indicated that he is unable to work because of the symptoms of his psychiatric disability. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). 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). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability 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 he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Based on the Board's decision above which grants an increase for PTSD, the Veteran has a combined rating of 70 percent; consequently, he meets the schedular threshold for determining entitlement to a TDIU rating. The only question remaining is whether there is evidence that the Veteran is unable to secure substantially gainful occupation as the result of his service-connected PTSD. The record dating during this period does not include any probative findings as to employability. The Board acknowledges that February 2010 statements from a VA psychiatrist and social worker note that the Veteran "had not" worked or "had been unable to" work. Neither the psychiatrist nor the social worker made a specific finding as to the Veteran's employability, however, and the statements appear to be recitations of the Veteran's history of not working. Nevertheless, the Board finds the evidence supports a finding of unemployability. The record reflects evidence of depression, anxiety, social withdrawal, significant irritability, and suicidal ideation and indicates that the Veteran experienced exacerbations of his psychiatric symptoms with periods of increased stress. Furthermore, the record documents the assignment of GAF scores corresponding to serious impairment or symptoms and assessments of "severe" PTSD and reflects histories of use of marijuana and alcohol to cope with the symptoms. When viewed on the whole, the Board finds the record suggests the Veteran's PTSD results in inability to obtain or maintain gainful employment. Thus, a TDIU is warranted. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). That burden has not been met in this case. Nevertheless, the record reflects that the appellant was provided a meaningful opportunity to participate effectively in the processing of his claim for a total rating prior to November 2, 2011, such that the notice error did not affect the essential fairness of the adjudication now on appeal. The appellant was notified that service connection was awarded with a 50 percent rating. He was provided notice how to appeal that decision, and he did so. He was provided a statement of the case that advised him of the applicable law and criteria required for a higher rating. An October 2006 letter, provided in conjunction with the original claim of service connection, also provided notice that disability ratings were assigned in accordance with the facts found as required by Dingess. 38 U.S.C.A. § 5110(a). Moreover, the record shows that the appellant was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). Thus, based on the record as a whole, the Board finds that a reasonable person would have understood from the information that VA provided to the appellant what was necessary to substantiate his claim, and as such, that he had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication was not affected. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The duty to assist was also met in this case. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file and adjudicated or had such adjudication waived (see April 2013 "Additional Evidence Response Form"), and the appellant has not contended otherwise. A VA examination with respect to the issue on appeal was obtained in April 2010. 38 C.F.R. § 3.159(c) (4). 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 examination provided in this case is adequate. The examiner reported all necessary findings and provided an opinion on the severity of the Veteran's PTSD which was consistent with the reported findings and evidence of record. The Board acknowledges that it is unclear whether the examiner reviewed the claims file. The examiner did elicit a medical history from the Veteran, which was consistent with that contained in the claims folder; hence, consideration of the current disability status was made in view of the Veteran's medical history. 38 C.F.R. § 4.1; Francisco v. Brown, 7 Vet. App. 55 (1994). As this is a claim of increase rather than of service connection, and as the Veteran provided a medical history which was an adequate substitute for a review of the medical record, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). ORDER A rating of 70 percent, but no higher, is granted for the period prior to November 2, 2011, subject to the regulations governing the payment of VA monetary benefits. A TDIU is granted for the period prior to November 2, 2011. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs