Citation Nr: 1322295 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 08-28 977 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a right hand tremor, claimed as due to exposure to an herbicide agent, to include as secondary to diabetes mellitus type II. 2. Entitlement to service connection for left hand tremor, claimed as due to exposure to an herbicide agent, to include as secondary to diabetes mellitus type II. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from December 1967 to July 1970. This matter comes on appeal before the Board of Veterans' Appeals (Board) from an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Veteran testified at a March 2010 Travel Board hearing before the undersigned. The hearing transcript has been associated with the claims file. In September 2011, the Board remanded the issues listed above, as well as the issue of entitlement to service connection for tinnitus. Service connection for tinnitus was established by the RO in August 2012; as such that issue is no longer in appellate status. The Board remanded the case again in December 2012. The December 2012 remand directed additional development that included a request to obtain supplemental medical opinions addressing the issues of service connection for right and left hand tremors. This was accomplished, and the Board concludes that it may proceed with a decision on those issues at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran is presumed to have been exposed to an herbicide agent during active service. 2. The Veteran did not exhibit chronic symptoms related to essential tremors in service or continuous symptoms since service separation. 3. Essential tremors did not manifest to a compensable degree in service or within one year of service separation. 4. Currently diagnosed essential tremors are not etiologically related to service, nor are they related to exposure to an herbicide agent in service. 5. Essential tremors are not etiologically related to a service-connected disability, to include diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for service connection for essential tremors of the right hand have not been met. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for essential tremors of the left hand have not been met. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a January 2008 letter, the RO provided preadjudicatory notice to the Veteran regarding what information and evidence is needed to substantiate the Veteran's claim for service connection on the merits, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The January 2008 VCAA notice letter also included information regarding provisions for disability ratings and for the effective date of the claim. The Veteran was afforded VA examinations in March 2009 and March 2013 to address claimed essential tremors and a September 2011 addendum opinion is of record. 38 C.F.R. § 3.159(c)(4) (2012). 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 and the most recent March 2013 VA medical opinions are adequate to address the etiology of claimed right and left hand tremors. A current diagnosis of essential tremors was identified and the March 2013 VA examiner provided an opinion based on a review of the record. For these reasons, the Board finds that the March 2013 VA opinion was based on an accurate factual background consistent with the Board's own findings in this case. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis); see also Nieves-Rodriguez v. Peake, 22 Vet.App. 295 (2008) (holding that "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion"). The Board finds that that the RO has substantially complied with the terms of the December 2012 remand order in obtaining the VA examination and medical opinions. The December 2012 remand order requested that the RO obtain a VA neurological examination and opinion to determine if essential tremors were incurred in service, related to exposure to an herbicide agent in service, or if they are secondary to service-connected diabetes mellitus. The Board finds that the March 2013 opinion adequately addresses the question of whether essential tremors are related to herbicide exposure in service and adequately addressed the issue of secondary service connection. The VA examiner included adequate reasons and bases for these opinions based the examiner's own medical knowledge and a review of pertinent medical literature. With regard to the question of whether essential tremors were incurred in service, within one year of service separation, or whether it was otherwise caused by service, the Board finds that the reasons and bases for the March 2013 opinion largely reiterated the rational provided in a prior September 2011 addendum, which the Board found was inadequate. The March 2013 VA examiner reasoned that his opinion was based on a review of the claims file, service treatment records, the Veteran's history, and the available medical records but did not provide further discussion as to his rationale. The Board finds, however, that an additional remand for a medical opinion is not necessary in this case. Because the Board has found that the Veteran did not exhibit symptoms related to essential tremors in service or shortly after service, because the March 2013 VA opinion adequately addresses whether essential tremors are related to exposure to an herbicide agent based on a review of the medical literature addressing presumptive conditions for such exposure, and because the weight of the evidence does not otherwise establish that the Veteran suffered a disease or injury in service which can be related to essential tremors, the Board finds that the evidence of record is adequate for disposition of the Veteran's claim and, thus, an additional medical opinion is not necessary. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). For these reasons, the Board finds that the March 2013 VA examination and medical opinions substantially complied with the terms of the December 2012 and the prior September 2011 remand order. See Stegall, 11 Vet. App. at 270. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue of service connection for right and left hand tremors has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, VA examinations, VA and private treatment records, and the Veteran's lay statements and testimony. The Veteran and his representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Board finds, in this case, that essential tremors are an organic disease of the nervous system, and thus qualify as a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served ninety days or more of active service, and certain chronic diseases, including organic diseases of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such 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 (West 2002); 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. Id. A veteran, who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii). The presumption of herbicide exposure is warranted for service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). In order to establish qualifying "service in Vietnam," a veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service. 38 C.F.R. § 3.307(a)(6)(iii); VAOPGCPREC 27-97. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). In this regard, the Board observes that VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended to certain specific disorders, based upon extensive scientific research. See, e.g., Notices, 68 Fed. Reg. 27,630 -41 (2003); 64 Fed. Reg. 59,232 -243 (1999); 61 Fed. Reg. 57,586 -589 (1996). However, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Under the current version of 38 C.F.R. § 3.310(b) which is applicable to this appeal, the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. These evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. See Notice, 71 Fed. Reg. 52,744-47 (Sept. 7, 2006), later codified at 38 C.F.R. § 3.310(b). In rendering a decision on appeal the Board must also 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. 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"). 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. See 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. See 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). Service Connection Analysis The Veteran contends that essential tremors are related to service, specifically, that they are due to Agent Orange exposure in service, or alternately, that they are due to service-conencted diabetes mellitus. After reviewing all the lay and medical evidence, including the Veteran's statements, the Board finds that the weight of the evidence demonstrates that currently diagnosed essential tremors are not related to service or to herbicide exposure in service, nor are they secondary to service-connected diabetes mellitus. The Veteran has currently diagnosed essential tremors. The earliest medical evidence of record showing a diagnosis of tremors is dated in November 2004. A November 2004 private treatment report from Dr. R.T. shows that the Veteran was referred for evaluation of tremor. The Veteran reported, at that time, that he had tremor for over 20 years, beginning in his left hand and later spreading to his right. He also reported a family history of tremor occurring in his father in his 60s. The Veteran was diagnosed with benign essential tremor, stated to be severe, disabling, and longstanding. March 2009 and March 2013 VA examinations confirm a current diagnosis of essential tremors in the right and left hands. The Veteran asserts that essential tremors are related to Agent Orange exposure in service. The Veteran's form DD-214 shows that he had service in the Republic of Vietnam from August 1968 to July 1979; thus, he is presumed to have been exposed to an herbicide agent during service. However, as the Veteran's claimed disability, essential tremors, is not included in the above-indicated diseases associated with exposure to an herbicide agent, presumptive service connection is not warranted. See 38 C.F.R. § 3.309(e). Even though presumptive service connection is not warranted, the Veteran is not precluded from establishing service connection for a diagnosed disability with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). The Board finds that the Veteran did not experience chronic symptoms related to an essential tremors in service and did not experience continuous symptoms related to essential tremors since service separation. The weight of the evidence demonstrates that the Veteran did not exhibit symptoms related to essential tremors in service. Service treatment records do not reflect any specific complaints or treatment related to essential tremors. While service treatment records do not include a separation examination, a VA general medical examination completed in October 1970, just a few months after the Veteran's separation from service, does not reflect any neurological or musculoskeletal complaints referable to either hand. Moreover, the Veteran does not contend that essential tremors were present in service, and instead testified during a March 2010 Board hearing that he first noticed essential tremors approximately 25 years earlier (in approximately 1985). The Veteran testified that he did not have essential tremors while he was in service and reported that essential tremors had their onset after service. The Board finds that this statement is credible and consistent with an earlier November 2004 history provided during the course of a private evaluation for tremors, in which the Veteran reported an approximate 20-year history of tremors. The Board finds that essential tremors did not manifest to a compensable degree in service or within one year of service separation. The earliest post-service diagnosis of essential tremors was in November 2004. The Veteran testified that essential tremors were not present in service, and in a November 2004 treatment report and during his Board hearing, he dated the onset of essential tremors to the mid-1980s. The Veteran is competent to report the approximate date of the initial onset of his tremors and the Board has found that his reports are credible. For these reasons, the Board finds that symptoms related to essential tremors were not identified for at least a decade after the Veteran's separation from service in 1970. Accordingly, the Board finds that symptoms related to essential tremors were not chronic in service or continuous since service separation. The Board finds that currently diagnosed essential tremors are not related to herbicide exposure in service and they are not etiologically related to a service-connected disability, to include diabetes mellitus. As noted above, the Veteran has credibly reported that he had the onset of tremors over a decade after service separation. In a June 2008 letter, the Veteran's primary care physician, Dr. C.F., identified the Veteran's current diagnoses, to include benign tremors, and noted past exposure to Agent Orange, but did not offer an opinion with regard to etiology. A March 2009 VA examination and opinion and a September 2011 addendum opinion indicate that essential tremors are less likely than not related to diabetes mellitus, associated peripheral neuropathy, or Agent Orange exposure; however, the VA examiner did not provide an adequate rational for the opinion rendered. For these reasons, the Board finds that the March 2009 and September 2011 opinions are of no probative value. See also Nieves-Rodriguez, 22 Vet. App. at 295. A March 2013 VA examiner opined that bilateral hand tremors were less likely than not related to exposure to an herbicide agent during the Veteran's period of active duty. The examiner reasoned that, according to a review of the medical literature, tremors were not a condition presumed to be related to exposure to an herbicide agent. The VA examiner also opined that bilateral hand tremors were not caused or aggravated by a service-connected disability, to include diabetes mellitus type II. He reasoned, based on a review of the medical literature, that diabetes mellitus does not cause or increase the severity of essential tremors. The March 2013 VA opinion was based on comprehensive physical examination of the Veteran for both essential tremors, diabetes mellitus, and associated disabilities and included a review of the claims file. The Board finds, therefore, that the opinion was based on an accurate factual background as well as the examiner's own medical expertise and information provided by an independent review of the applicable medical literature. For these reasons, the Board that the March 2013 opinion provides competent, credible, and probative evidence showing that essential tremors are not related to exposure to an herbicide agent in service, and are not caused or aggravated by service-connected diabetes mellitus. Insomuch as the Veteran asserts that essential tremors may be related to exposure to Agent Orange in service, or that it may alternately be due to diabetes mellitus, the Board finds that he is not competent to provide a diagnosis of a neurological disability as complex as essential tremors absent any symptoms shown in service, and the Board finds that his lay assertions are of little probative value in light of the March 2013 VA examiner's assessment that is based on the Veteran's medical history, physical examination, and the examiner's own medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Bardwell, 24 Vet. App. at 40 (holding that a layperson's assertions indicating exposure to gases or chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service). The Board finds that essential tremors are not otherwise shown to be related to service either by a medical nexus opinion or by chronicity and continuity of symptomatology. For these reasons, the Board finds that the weight of the evidence shows that essential tremors in the right and left hand are not etiologically related to service. As the weight of the competent, credible, and probative evidence shows that currently diagnosed essential tremors of the right and left hands are not related to service, to exposure to an herbicide agent in service, or to service-connected diabetes, the Board finds that service connection is not warranted. Because the preponderance of the evidence is against the claim for service connection for essential tremors of the right and left hands the claim must be denied, and the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for essential tremors of the right hand is denied. Service connection for essential tremors of the left hand is denied. REMAND Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). The Board remanded entitlement to a TDIU in December 2012 for a supplemental opinion to determine whether the Veteran's service-connected disabilities alone have prevented the Veteran from engaging in substantially-gainful employment consistent with his education and occupational experience. The Veteran was afforded VA examinations in March 2013 to address service-connected coronary artery disease, diabetes mellitus, diabetic retinopathy, peripheral neuropathy, hearing loss and tinnitus, and a right ankle disability, which included a discussion of the occupational impairment caused by each disability. The Veteran's representative contends in a June 2013 statement that these separate examinations fail to provide information as to whether the Veteran's service-connected disabilities, in combination, render him unable to follow or secure substantially gainful occupation. The Board is in agreement and finds that an additional medical opinion is necessary to comply with the terms of the December 2012 remand order. See Stegall v. West, 11 Vet. App. 268, 270 (1998), (holding that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should refer the case to an appropriate VA examiner for a supplemental medical opinion regarding entitlement to a TDIU. Another examination is not required. The claims folder should be made available for review in connection with this request. The examiner should offer the following opinion: Without regard to the Veteran's age or the impact of any nonservice-connected disabilities, but with regard to his education level, state whether it is at least as likely as not that the Veteran's service-connected disabilities, in combination (coronary artery disease, diabetes mellitus, diabetic retinopathy, peripheral neuropathy of the right arm, left arm, right leg, and left leg, bilateral tinnitus, bilateral hearing loss, right ankle impairment, and erectile dysfunction) preclude him from engaging in substantially-gainful employment. The examiner must review all pertinent records associated with the claims file and to comment on the effect of the Veteran's service-connected disabilities on his ability to engage in any type of full-time employment and whether, in the examiner's opinion, the service-connected disabilities alone are of such severity to result in unemployability. The examiner should provide a rationale for his or her opinion with reference to the evidence of record and should provide a discussion of the facts and medical principles involved. 2. The RO/AMC must review the VA opinion to ensure that they are in complete compliance with this remand. If it is deficient in any manner, the RO/AMC should implement corrective procedures at once. 3. After all development has been completed, the RO/AMC should readjudicate the issues of entitlement to a TDIU. If the benefits sought remain denied, the Veteran and his representative should be furnished a supplemental statement of the case, and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs