Citation Nr: 1320334 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 96-44 133 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a rating in excess of 10 percent for atopic dermatitis. 2. Entitlement to service connection for chronic urticaria, to include as due to service-connected skin disabilities. 3. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran had active service from October 1974 to July 1976. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from the June 1996 and December 1997 rating decisions of the Montgomery, Alabama, Regional Office (RO). The June 1996 rating decision continued a 10 percent rating for atopic dermatitis. The December 1997 rating decision, in pertinent part, denied service connection for chronic urticaria and the claim for a TDIU. This matter was previously before the Board in November 1998, April 2001, July 2003, April 2009, April 2011, and February 2013; on each occasion, it was remanded for further development of the evidence. The required development has been completed and this case is appropriately before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. For the entire rating period, atopic dermatitis has not covered 20 to 40 percent of the Veteran's entire body or 20 to 40 percent of exposed areas affected and has not required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six week or more, but not constantly during the past 12 month period. 2. Chronic urticaria was not shown in service or for many years after service; the current urticaria is not causally or etiologically related to service or to service-connected skin disabilities. 3. The Veteran's service-connected disabilities do not render her unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for atopic dermatitis have not been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.21, 4.118, Diagnostic Code (DC) 7806 (2012). 2. Chronic urticaria was not incurred in or aggravated by service nor is it secondary to the service-connected skin disabilities. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310(a) (2012). 3. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 3.340, 3.341, 4.15, 4.16, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive 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 claims. Unfortunately, the Veteran's original claims folder was lost and numerous attempts have been made to rebuild the claims folder, which have met with limited success. Hence, there is a heightened obligation for VA to assist her in the development of her claim and to provide reasons or bases for any adverse decision rendered without these records. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). During the course of the appeal, the Veteran reported for VA examinations in June 1996, September 1997, December 2002, with the December 2002 VA examiner providing an addendum in February 2003. The RO requested a medical opinion for the claim of service connection for chronic urticaria which was obtained in April 2013. She failed to report for VA examinations scheduled in February 2009, July 2010, and December 2012; therefore, the claims will be based upon the evidence of record. See 38 C.F.R. § 3.655(b). Given the complexity of the Veteran's skin conditions, the Board notes that some treatment records and VA examination reports discuss both of the issues on appeal (chronic urticaria and atopic dermatitis). Therefore, the Board will provide a discussion of the relevant evidence of record and then separately address the increased rating claim for atopic dermatitis and service connection claim for chronic urticaria. The evidence of record includes a June 1996 VA examination report. During the evaluation, the examiner reported eczematous erythema associated with the face sparing the forehead, involving the eyelids and underneath the chin. Upon noting the Veteran's medical history, the examiner stated that she had been diagnosed with chronic urticaria and had been treated with topical steroids and was currently on continuous Prednisone (a corticosteroid). The June 1996 examination report did not specifically discuss atopic dermatitis. In a following September 1996 VA treatment record, the examining physician noted that the Veteran had a history of severe chronic urticaria for 1.5 years (i.e., approximately 1994). In a September 1997 VA examination report, the examiner stated that the Veteran complained of chronic urticaria since 1994. It was noted that she was requesting increased compensation from her condition (chronic urticaria) due to the debilitating effects of her disease and recent progression within the last several years. A diagnosis of atopic dermatitis was also reported, however, the examiner stated "this is much less troublesome to her [the Veteran] and not the condition for which she seeks increased compensation." During the evaluation, and while discussing symptoms of urticaria, it was noted that the Veteran had steroids repeatedly administered to her in the last several years and, at one point, took them on a daily basis. The September 1997 examiner diagnosed the Veteran with chronic urticaria and "contact dermatitis vs. lupus vs. rosacea, of the face." The examiner reasoned that atopic dermatitis and urticaria were "two separate entities." Although the Veteran had a diagnosis of atopic dermatitis, upon speaking with her, the examiner noted that she seemed to have more of a history of dyshidrotic eczema (eczema of the hands and feet). The examiner stated that dyshidrotic eczema was a separate entity and not the diagnosis for which she sought VA compensation. The Board notes that in a February 2013 decision, the Board granted service connection for dyshidrotic eczema. A subsequent December 2002 VA examination report did not discuss or provide a diagnosis for atopic dermatitis or chronic urticaria. It was noted, however, that the Veteran was continuing her immunosuppressive drugs for actinic dermatitis. In an April 2013 VA dermatological medical opinion, the examiner stated that atopic dermatitis was a chronic inflammatory skin condition that appeared to involve a genetic defect in the proteins supporting the epidermal barrier. The examiner opined that atopic dermatitis and chronic urticaria were separate from a medical perspective. Even if these conditions overlapped in the terms of symptoms and treatment, the examiner stated that they were separate in terms of etiology. Finally, the evidence of record also includes a November 1996 Social Security Administration (SSA) disability determination. The SSA determination found that the Veteran had severe impairment for urticaria, photosensitivity, asthma, and chronic actinic dermatitis. Further, the Veteran was found to have retained the residual functional capacity for sedentary work. Increased Rating for Atopic Dermatitis 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. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and 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. 38 C.F.R. §§ 3.102, 4.3, 4.7. During an appeal of a disability rating, either from an initial rating assigned on granting of service connection, or on appeal of a subsequent denial of an increased rating, it may be found that are varying and distinct levels of disability impairment severity during an appeal. So, staged ratings (different disability ratings during various time periods) are appropriate 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 all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that effective on October 23, 2008, VA amended the Schedule for Rating Disabilities by revising that the portion that addresses the skin, so that it more clearly reflected VA's policies concerning the evaluation of scars. Specifically, these amendments concern 38 C.F.R. § 4.118, DCs 7800-7805. This amendment does not apply to the Veteran's claim, as her application for benefits was received by VA prior to October 23, 2008. The Veteran's skin disorder is currently rated under DC 7800 (disfigurement of the head, face, or neck); however, the Board finds that the more appropriate DC is 7806, which specifically provides rating criteria for dermatitis. Under this DC, a 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for dermatitis covering 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six week or more, but not constantly during the past 12 month period. A 60 percent rating is assigned for dermatitis covering more than 40 percent of the entire body or more than 40 percent of exposed areas affected or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12 month period. Upon review of the evidence of record, discussed in detail above, the Board finds that a higher rating in excess of 10 percent is not warranted for atopic dermatitis. The medical evidence of record does not demonstrate that the Veteran's atopic dermatitis covers 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected. In the June 1996 VA examination, it was noted that eczematous erythema (redness or rash) affected the face sparing the forehead, eyelids and underneath the chin. In September 1997, the Veteran reported that her atopic dermatitis was much less troublesome than her urticaria. The Board finds that this evidence demonstrates that her atopic dermatitis does not more nearly approximate 20 to 40 percent coverage of the entire body or 20 to 40 percent of exposed areas affected under DC 7806. The Board further finds that the Veteran's atopic dermatitis has not required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six week or more, but not constantly during the past 12 month period. In this regard, the Board acknowledges that she has been treated with continuous corticosteroids and other immunosuppressive drugs, however, this treatment has related to chronic urticaria and actinic dermatitis, and not for atopic dermatitis. For example, in June 1996, the examiner stated that the Veteran had been diagnosed with chronic urticaria and had been treated with topical steroids and was currently on a continuous corticosteroid. In the September 1997 VA examination, while discussing symptoms of urticaria, it was reported that she had steroids repeatedly administered to her over the last several years. In December 2002, she was continuing her treatment with immunosuppressive drugs for actinic dermatitis (photosensitivity). Finally, the Board notes that the Veteran failed to report for the most recent VA examination scheduled in December 2012. With respect to the Veteran's claim, the Board has also considered her statements that her skin disability is worse. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. Layno, 6 Vet. App. at 470. She is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. For these reasons, the Board finds that the weight of the evidence demonstrates that her atopic dermatitis has not more nearly approximates the 30 percent rating criteria under DC 7806 for the entire rating period on appeal. As such, the preponderance of the evidence is against this claim, and the benefit-of-the-doubt doctrine does not apply. As such, the appeal is denied. Next, the Board has applied Mittleider v. West, 11 Vet. App. 181 (1998) and has attributed all the Veteran's relevant symptoms to her service-connected disability. With that in mind, the Board has considered whether referral for extraschedular consideration is warranted. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extraschedular evaluation is made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability and the established criteria found in the rating schedule to determine whether a veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimants exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Thun, 22 Vet. App. 111; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The record does not establish that the rating criteria are inadequate. To the contrary, the very symptoms that the Veteran described, itching, redness, and skin irritation, are the symptoms contemplated by the criteria found in the rating schedule for her disability. Because the schedular rating criteria is adequate to rate the skin disability, the other two steps in the analysis of extra-schedular ratings need not be reached. In the absence of exceptional factors associated with the Veteran's atopic dermatitis disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Service Connection for Chronic Urticaria Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. In this case, continuity of symptoms is required. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). In this case, chronic urticaria is not listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In this case, as above, chronic urticaria is not listed in 38 C.F.R. §§ 3.307, 3.309(a); therefore, the one-year presumption does not apply. Service connection may also be established for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. In this decision, the Board has considered the lay evidence as it pertains to service connection for chronic urticaria. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). "Competent medical evidence" means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). A veteran is competent to report symptoms that she experiences at any time because this requires only personal knowledge as it comes to her through her senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to evaluating the medical evidence, generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). At the outset, the Board finds that the Veteran has a current diagnosis of chronic urticaria. In a September 1996 VA treatment record, the examining physician noted that the Veteran had a history of severe chronic urticaria for 1.5 years. As noted above, service treatment records are missing; however, service connection is currently in effect for atopic dermatitis and dyshidrotic eczema, indicating that she had at least some skin problems in service. That notwithstanding, the Board finds that the weight of the evidence of record demonstrates that chronic urticaria is neither related to service nor to a service-connected skin disability. In this regard, as discussed above, the RO requested a medical opinion to determine the etiology of the Veteran's chronic urticaria disorder. In the April 2013 VA dermatological medical opinion, the examiner stated that chronic urticaria was defined by the presence of hives on most days of the week, for a duration of longer than six weeks. The prevalence of this disorder was noted as up to 1% of the general population. Atopic dermatitis, on the other hand, was noted as a chronic inflammatory skin condition that appeared to involve a genetic defect in the proteins supporting the epidermal barrier. The Veteran's service-connected disabilities (atopic dermatitis and dyshidrotic eczema) were noted as beginning in service; however, the examiner found that the onset of chronic urticaria was in the early to mid 1990s. The examiner opined that these conditions were separate from a medical perspective. Even if these conditions overlapped in the terms of symptoms and treatment, the examiner stated that they were separate in terms of etiology. Accordingly, the examiner opined that chronic urticaria was less likely than not related to or caused by the Veteran's service, and was less likely than not related to or caused by her service-connected disabilities. The Board finds that the April 2013 VA medical opinion is competent and probative medical evidence because it is factually accurate and based on sound reasoning. The VA examiner was informed of the relevant evidence in this case and provided a fully articulated opinion supported by medical literature. The Board finds that the medical evidence sufficiently addressed the issue of whether the Veteran's chronic urticaria is relate to service and whether it was proximately due to or aggravated by her service-connected skin disabilities. The Board acknowledges that the April 2013 examiner did not specifically state whether chronic urticaria was aggravated by the service-connected disabilities; however, the Board finds that a fair reading of the medical opinion sufficiently addresses both the issue of proximate cause and aggravation, and therefore, does not warrant a remand for an additional medical opinion to decide the claim. See 38 C.F.R. § 3.159(c)(4). Specifically, the examiner stated that "these conditions [chronic urticaria and atopic dermatitis] are separate conditions from a medical perspective." Further, the examiner specifically noted the symptoms of chronic urticaria (hives) versus atopic dermatitis (chronic inflammatory skin condition). It was also opined that chronic urticaria was less likely than not related to the Veteran's service-connected disabilities. The Board finds that a plain reading of the opinion provided by the VA examiner encompasses the question of aggravation. Moreover, the Board notes that during the September 1997 VA examination, the Veteran complained of chronic urticaria since 1994. It was reported that she was requesting increased compensation for her condition (chronic urticaria) due to the debilitating effects of her disease and recent progression within the last several years. She also reported that atopic dermatitis was much less troublesome to her. It does not appear, from the Veteran's own statements, that her service-connected dyshidrotic eczema and/or atopic dermatitis, which were noted as "less troublesome," were permanently aggravating her urticaria. Based on the evidence of record, the Board finds that the weight of the competent evidence is against a finding of relationship between chronic urticaria and service, to include as secondary to the service-connected skin disabilities, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. TDIU TDIU may be assigned where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities; provided that, if there is only one such disability, this disability is ratable at 60 percent or more, and that if there are two or more disabilities, there is at least one disability ratable at 40 percent or more, and sufficient additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). In addition, the Board has considered 38 C.F.R. § 3.340 which provides that a total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. In other words, 38 C.F.R. § 3.340 deals with the average person standard and 38 C.F.R. § 4.16(a) deals with the particular individual. The award of a total rating requires a showing that the veteran is precluded from employment due to service connected disabilities. The adverse affects of advancing age may not be considered in support of the claimed benefit. 38 C.F.R. § 4.19. 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 a veteran's education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board must determine if there is some service-connected factor outside the norm which places a veteran in a different position than other veterans with the same rating. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The fact that a veteran is unemployed or has difficulty obtaining employment is not enough as a schedular rating provides recognition of such. Id. Rather, he or she need only be capable of performing the physical and mental acts required by employment. Id. The schedular criteria contemplate compensating a veteran for considerable loss of working time from exacerbations proportionate to the severity of the disability. See 38 C.F.R. § 4.1. In this case, the Veteran's current service-connected disabilities are atopic dermatitis and dyshidrotic eczema, each rated at 10 percent. Accordingly, her combined rating is 20 percent. See 38 C.F.R. § 4.25, Table I Combined Rating Table. Therefore, she does not meet the minimum percentage requirements of 38 C.F.R. § 4.16(a). Nevertheless, where the schedular percentage requirements for total disability rating for compensation based on individual unemployability have not been met, an extraschedular rating may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. Consideration is given to the veteran's service-connected disabilities, employment history, educational and vocation attainments, and any other applicable factor. 38 C.F.R. § 4.16(b). Considering the pertinent evidence in light of the above, the Board finds that a TDIU on an extraschedular basis is not warranted. Notably, in March 2013 the RO sent the Veteran a letter requesting her to submit any additional evidence to support her claim for a TDIU. To date, she has not responded. In September 2010, she was also scheduled for a VA examination in order to obtain a medical opinion and to determine the extent of her functional impairment due to her service-connected disabilities; however, she failed to report for the examination. Further, in September 1997, the examiner diagnosed the Veteran with chronic urticaria and "contact dermatitis vs. lupus vs. rosacea, of the face." During the evaluation, she reported constant itching and that she stopped working in July 1994 due to her chronic urticaria disorder. The examiner also noted that atopic dermatitis should not affect her unemployability. The Board has considered the Veteran's statement that she stopped working because of her chronic urticaria; however, because chronic urticaria is not a service-connected disability, the Board finds that a TDIU is not warranted based on this disorder. The evidence of record also includes a November 1996 SSA disability determination. Although SSA determinations regarding unemployability and disability are not binding on VA, they may be relevant in disability determinations. See Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). The SSA determination found that the Veteran had severe impairment for urticaria, photosensitivity, asthma, and chronic actinic dermatitis. Notably, none of these disabilities are service-connected through VA. Further, the SSA determination found that the Veteran had retained the residual functional capacity for sedentary work. After a review of the entire record, the Board finds that the weight of the evidence is against the claim for a TDIU. Although the service-connected atopic dermatitis and dyshidrotic eczema may present difficulties in an occupational environment, the disabilities are not to the degree that prevents the Veteran from obtaining and maintaining substantially gainful employment. Therefore, the Board finds that the criteria for a TDIU are not met. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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 of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, a letter satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) was sent to the Veteran in January 2009. The letter informed her of what evidence was required to substantiate the claim and of her and VA's respective duties for obtaining evidence. Moreover, with respect to the Dingess requirements, the Veteran was given notice in March 2006 of what type of information and evidence she needed to substantiate her claim for an increased rating as this is the premise of the claim. It is therefore inherent that the she had actual knowledge of the rating element of the claim. Further, numerous supplemental statements of the case also provided her with notice of the type of evidence necessary to establish an effective date for the disability on appeal. Any questions as to the appropriate effective date to be assigned are moot as the claim has been denied. Based on the above, the notice deficiencies do not affect the essential fairness of the adjudication. Therefore, the presumption of prejudice is rebutted. For this reason, no further development is required regarding the duty to notify. Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As noted above, the Veteran's original claims folder was lost and numerous attempts have been made to rebuild the claims folder which has resulted in limited success. Accordingly, there is a heightened obligation for VA to assist her in the development of her claim and to provide reasons or bases for any adverse decision rendered without these records. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In this regard, the RO has obtained VA treatment records, private treatment records, and SSA disability records. Further, the Veteran was afforded VA examinations in June 1996, September 1997, December 2002 with a February 2003 addendum, and April 2013. As explained in detail above, the Board finds that the conclusions reached and rationale given in the April 2013 VA examination are adequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran failed to report for VA examinations scheduled in February 2009, July 2010, and December 2012; therefore, the claims have been adjudicated based upon the evidence of record. See 38 C.F.R. § 3.655(b). See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). Significantly, neither the Veteran nor her representative have identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A rating in excess of 10 percent for atopic dermatitis is denied. Service connection for chronic urticaria, to include as due to service-connected skin disabilities, is denied. A TDIU is denied. ______________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs