Citation Nr: 1322572 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-42 852 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with secondary depression. 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Teena Petro, Agent ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from March 1966 to March 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. FINDINGS OF FACT 1. For the entire rating period, the Veteran's PTSD has been manifested by symptoms of nightmares, chronic sleep impairment, difficulty concentrating, some social isolation, anxiety and depression; the symptoms cause some occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. For the entire rating period, the Veteran's PTSD has not been characterized by 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 3. The Veteran is service-connected for PTSD with secondary depression, rated as 50 percent disabling, bilateral defective hearing, rated as 0 percent disabling and tinnitus, rated as 10 percent disabling. The combined evaluation of the Veteran's service-connected disabilities is 60 percent. 4. The weight of the competent, probative and credible evidence does not demonstrate that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD have not been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.340, 3.341(a), 4.16, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by 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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ), in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence required to substantiate the claim, namely evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in April 2008. The letter provided the information required by Vazquez and advised the Veteran of the evidence required to substantiate the claim for a TDIU. The letter informed the Veteran of the Veteran's and VA's respective duties for obtaining evidence. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the record indicates that the RO obtained all information relevant to the Veteran's claims. Moreover, the Veteran underwent adequate and probative VA medical examinations for his increased rating and TDIU claims. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). 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). The RO has obtained relevant records, and has provided adequate examinations to the Veteran. Significantly, neither the Veteran nor his representative has 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 to the Veteran is required to fulfill VA's duty to assist the Veteran 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). II. Analysis of Claims Rating Criteria Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluation shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). PTSD is evaluated (rated) under the general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this general rating formula, a 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating, may be 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 work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent schedular evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130 , DC 9411. As noted below, treatment providers have rendered Global Assessment of Functioning (GAF) scores pursuant to the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). As indicated in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995), the GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. A score in the range of 51 to 60 indicates moderate symptoms (e.g., a flattened affect, circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41 to 50 reflects a serious level of impairment (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 31 to 40 reflects some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood and an inability to work. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See also 38 C.F.R. § 4.126(a)(an evaluation shall be based on all the evidence of record that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of examination). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). Increased Rating for PTSD with Depression Service connection for PTSD with depression was granted in a March 1993 rating decision. A 10 percent rating was assigned from February 1991. A 30 percent rating was assigned from February 1998. A 50 percent rating was assigned from December 1999. A claim for an increased rating was received in February 2008. In his February 2008 claim, the Veteran contended that PTSD with depression had gotten worse. The Veteran asserted that he is overly anxious and is not able to cope with daily living and the stresses associated with employment. In the September 2008 notice of disagreement and the December 2009 substantive appeal, the Veteran contended that PTSD was worse. A VA treatment record dated in February 2008 reflects that a VA psychiatrist noted that the Veteran was well-groomed, alert and cooperative. The VA psychiatrist indicated that the Veteran's cognitive functions were intact, and his affect was euthymic. Anxiety was mild to moderate, and depressed mood was not apparent. The Veteran reported that he sometimes felt he was having a panic attack. The VA psychiatrist indicated that content of thought revealed no psychotic symptoms and no aggressive ideations. Assessment was PTSD with chronic moderate anxiety. A VA psychiatry treatment note dated in April 2008 reflects that the Veteran reported that he was feeling better and that medication was helping to make him calm and relaxed. The Veteran reported that his anxiety had subsided, and he felt depressed. The VA psychiatrist indicated that the Veteran had good eye contact and good affect. His thought process was integrated. He had no suicidal and aggressive ideations, and no psychotic symptoms were elicited. The Veteran was in good control of his impulses. Insight was present, and he had good judgement. The Veteran had a VA examination in August 2008. The Veteran reported sleep disturbances, exacerbation of job stress, intrusive thoughts, family and interpersonal difficulties, isolation, anxiety and difficulty in attention and concentration. The Veteran reported that he had not lost much time from work in the past 12-month period. The Veteran reported social impairment due to isolation on the job. He reported much job-related stress which exacerbated his symptoms. The Veteran reported that he had some friends at work and outside work, but the relationships were minimal. The Veteran reported that his relationship with his spouse was adequate. On mental status examination in August 2008, the VA examiner noted that there was no impairment of thought processes or communication reported or observed. The Veteran was interpersonally appropriate at all times and was polite and cooperative. The Veteran was well-groomed and cared for, with no sign of poor hygiene. The Veteran was oriented in all three spheres, with intact recall for recent and remote events. The Veteran reported that he had difficulty with short-term memory at times. With regard to obsessive and ritualistic behaviors, the Veteran reported that he routinely checked his house to make sure it was safe. He reported that this sometimes interfered with his sleep. The VA examiner noted that the Veteran's ideas were logical and sequential, and his speech was intelligible and understandable. The VA examiner noted that the Veteran's communications were terse but were reality based. The Veteran reported that panic attacks occurred occasionally. The VA examiner noted that the panic attacks were situational with events consistent with PTSD, such as being in crowds and being bothered by war-related stimuli. The Veteran reported that, while he was anxious at times, he was depressed "to some extent, not all of the time." The VA examiner indicated that impaired impulse control and effect on motivation or mood were not reported or observed. The Veteran reported sleeping at most four hours per night. The Veteran reported that this interfered with daytime activities. The VA examiner assigned a GAF score of 55. The VA examiner indicated that the Veteran is capable of managing his own affairs. The VA examiner indicated that the Veteran was employed. It was noted that he was planning retirement but was not sure of the retirement date. The VA examiner noted that PTSD was somewhat of a work issue for the Veteran. It was noted that the Veteran's job tended to be solitary and stressful, and the Veteran reported that PTSD made his job more difficult, but the Veteran appeared to be maintaining a functional role in the company in the role of a fork truck driver. The VA examiner opined, after reviewing the Veteran's records and interviewing the Veteran, there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to signs and symptoms but generally satisfactory functioning in routine behaviors and self-care. A VA outpatient treatment note dated in July 2008 reflects that the Veteran reported stress, especially at work, sleeping problems and nightmares. The Veteran reported that he was gainfully employed and on sick leave for a week. A VA psychiatrist noted that the Veteran was anxious and depressed. The psychiatrist indicated that the Veteran's thought process was integrated. Suicidal and aggressive ideations and psychotic symptoms were denied and were not elicited. The Veteran's cognition was good. A VA outpatient treatment note dated in September 2008 reflects that the Veteran reported that he continued to struggle with chronic symptoms associated with PTSD. The Veteran denied suicidal or homicidal ideation. A VA psychiatry treatment note dated in February 2009 noted that the Veteran was well-groomed, alert, cooperative, and friendly. The VA psychiatrist noted good eye contact and fair affect. The Veteran's cognitive functions were intact. His speech was fluent and soft-spoken. The VA psychiatrist indicated that the Veteran's anxiety and depressed mood appeared mild. The Veteran reported that he was about to retire after 40 years of service. His thought process was sequential, logical and goal-directed. The VA psychiatrist noted that the Veteran had no suicidal or homicidal ideations and no psychotic symptoms. The Veteran submitted an evaluation from a private psychologist, dated in January 2010. The mental status examination reflects that the Veteran was neatly groomed and oriented to person, place and time. The Veteran reported that he had experienced delusions and hallucinations in the past. The Veteran reported that he had depression that was a seven on a scale of one to ten. He reported that, despite taking an anti-depressant, he still felt very depressed. The Veteran reported that he was very anxious, despite taking medication to cope with anxiety. The examiner indicated that the Veteran reported difficulty concentrating characterized by re-reading materials and difficulty remembering people's names. A GAF score of 38 was assigned. The psychologist indicated that the highest GAF score in the last 12 months was 39. A VA psychosocial assessment dated in November 2011 reflects that the Veteran reported struggling with marital issues which were unresolved for several years. A VA social worker indicated that the Veteran displayed anger and a negative outlook on life, along with ongoing PTSD, anxiety and depressive symptoms. A GAF score of 54 was assigned. The Veteran had a VA examination in October 2012. The Veteran reported that his mood was stable, though low level lethargy and lack of motivation were intermittent concerns. The VA examiner noted that there was marital conflict, that was better but still seemed to be a chronic stressor for the Veteran. No suicidal or homicidal ideation was endorsed. The Veteran reported that he volunteered at community organizations to keep busy. The VA examiner noted that a psychiatrist assessed GAF scores in the past year of 57 and 60, with 60 being the most recent. On mental status examination, the Veteran was dressed casually, with appropriate grooming and hygiene. There was no psychomotor agitation or retardation noted. The Veteran was alert. He was oriented to self, location and circumstances of visit. His speech was average in rate and rhythm. His affect was neutral. His thought process was organized and goal-directed. There was no suicidal ideation endorsed and no threats to harm others. His insight and judgement were fair. The VA examiner indicated that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The VA examiner noted the GAF scores of 38 and 39 assigned in the private statement and indicated that the evaluation did not discuss the Veteran's functioning level, and in the examiner's experience, a GAF score of 38 would require a person to be hospitalized. The Board finds that overall the Veteran's PTSD symptoms and the severity of his symptoms more closely approximate the criteria at Diagnostic Code 9411 for a 50 percent evaluation for PTSD for the entire increased rating period, and do not more nearly approximate the criteria for a 70 percent disability rating at any time during the rating period. 38 C.F.R. §§ 4.3, 4.7. For the entire rating period, the Veteran's PTSD has not been characterized by 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. In this regard, the Veteran has not reported suicidal ideation. The Veteran reported obsessional rituals of inspecting the area around his house, but the evidence does not show that this ritual interferes with routine activities. The Veteran has demonstrated logical speech and intelligible thought. The Veteran has reported depression, but the evidence does not indicate near-continuous depression that affects the ability to function independently, appropriately and effectively. The evidence reflects that the Veteran reported that PTSD made his job difficult sometimes, but VA examiners noted that he was able to maintain a functional role in his company. The GAF scores assigned by VA medical professionals during the appeal period are indicative of moderate impairment. The Board acknowledges the GAF score of 38 assigned by the private psychiatrist who evaluated the Veteran in January 2010. The Board has considered the GAF score in determining the appropriate rating for the Veteran's disability. Although a GAF score of 38 was assigned by the private physician, the evidence of record does not reflect findings of impairment in reality testing or major impairment in areas such as work, family relations, judgment, thinking or mood. The other GAF scores assigned by VA professionals during the appeal period have ranged between 54 and 60. The Board finds that, taking into account all of the GAF scores assigned, the overall level of symptomatology demonstrate moderate impairment. The Board notes that the Veteran has occasionally reported hallucinations during the appeal period. For example, he reported hallucinations upon VA examination in August 2008. Although persistent hallucinations would be consistent with the criteria for a 100 percent disability rating under DC 9411, the overall disability picture shown by the evidence does not demonstrate the presence of persistent hallucinations. The Veteran's demonstrated symptoms do not include: gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, persistent delusions or hallucinations, intermittent inability to perform activities of daily living, disorientation to time or place, memory loss for names of close relatives, own occupation, or own name to warrant a total disability rating. Therefore, the Board finds that the criteria for a 100 percent rating are not met. For these reasons, the Board finds that the weight of the lay and medical evidence demonstrates that the criteria for an increased rating for PTSD with secondary depression have not been met. As there is a preponderance of the evidence against the claim, the claim must be denied, and there is no reasonable doubt to resolve in the Veteran's favor. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on the severity of social and occupational impairment, history, symptomatology, and clinical findings. In this case, the Veteran's PTSD has manifested nightmares, chronic sleep impairment, some social avoidance, difficulty concentrating, anxiety and depression. Moreover, the Veteran's GAF scores ranged from 55 to 75, indicative of mild to moderate social and occupational impairment. These symptoms are part of, or similar to, the schedular rating criteria. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan at 442. Additionally, the Board has considered the GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of PTSD symptoms or overall functional impairment caused by PTSD. There remains no PTSD symptom or impairment that is not explicitly contemplated by the schedular rating criteria, or rated like or similar to the schedular rating criteria, and that has not been considered in the overall assessment of occupational and social impairment as reflected by the GAF scores assigned, which the Board has weighed and considered in determining the appropriate ratings to assign in this case for the respective periods. Because the schedular rating criteria is adequate to rate the Veteran's PTSD, no extraschedular referral is required. TDIU Legal Criteria The Veteran seeks a total disability rating based on individual unemployability due to his service-connected disabilities. A Veteran may be awarded a TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. A total disability rating 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 a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to age or the impairment caused by any non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Where a Veteran is unemployable by reason of his or her service-connected disabilities, but they fail to meet the percentage standards set forth in § 4.16(a), TDIU claims should be submitted to the Director, Compensation and Pension Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). The Board is precluded from assigning a TDIU rating on an extraschedular basis in the first instance. Instead, the Board must refer any claim that meets the criteria for referral for consideration of entitlement to TDIU on an extraschedular basis to the Director, Compensation and Pension Service. The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the Veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In Van Hoose v. Brown, 4 Vet. App. 361 (1993), the Court noted, "For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which takes the claimant's case outside the norm of such veteran...The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment." When all the evidence is assembled, VA is responsible for determining whether the evidence supports the clam 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. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU Analysis In his claim for entitlement to a TDIU, the Veteran reported that he last worked in February 2008. The Veteran indicated that he is unable to work due to service-connected PTSD. Service connection is in effect for PTSD with secondary depression, rated as 50 percent disabling, tinnitus, rated as 10 percent disabling and bilateral defective hearing, rated as 0 percent disabling. The combined rating for the Veteran's service-connected disabilities is 60 percent. The combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) are not met because the Veteran does not have one service-connected disability with an evaluation of at least 60 percent, or two or more disabilities with a combined rating of at least 70 percent with one disability rated at 40 percent. However, a TDIU evaluation can still be awarded if it is established by the evidence of record that service-connected disabilities have rendered the Veteran unable to secure and follow substantially gainful employment. If this is established, the case is to be sent to the Director of Compensation and Pension for extraschedular consideration. See 38 C.F.R. §§ 3.340(a), 3.341(a), 4.16(b). After a review of all the evidence, the Board concludes that the weight of the evidence demonstrates that a TDIU is not warranted for any period, in that the weight of the evidence is against a finding that the Veteran is unable to secure or follow substantially gainful employment due to his service-connected disabilities. VA records dated in February 2008 noted that the Veteran had spent five days in the Fort Wayne VA because of high blood pressure and a "light stroke." The Veteran reported that he felt that he could not return to work due to continued weakness all over, no strength, slurred speech and being off-balance. A VA psychiatry treatment note dated in April 2008 reflects that the Veteran reported that he was still working and planned to retire in 9 months after 40 years of continued employment. A report of an August 2008 VA examination reflects that the Veteran reported that he had not lost much time from work over the past 12-month period. He reported some social impairment due to isolation on the job. The Veteran reported much job-related stress. The VA examiner opined that the Veteran's performance in employment appeared to be adequate. The VA examiner noted that the Veteran was employed and intended to remain employed. It was noted that the Veteran was planning retirement but was not sure when his retirement date would be set. The VA examiner indicated that PTSD was somewhat of a work issue for the Veteran. The VA examiner noted that the Veteran's job was solitary but was stressful, and the Veteran reported that PTSD made the job somewhat more difficult. The VA examiner indicated that the Veteran appeared to be maintaining a functional role in the company. A report of a VA general medical examination dated in July 2008 did not address the impact of the Veteran's service-connected disabilities on his employability. A VA outpatient treatment record dated in February 2009 reflects that the Veteran reported that he was planning for retirement in one month due to his physical health. In a written statement dated in March 2009, the Veteran indicated that he retired in March of 2009, on the advice of a physician, because of his health problems. An October 2012 VA examination for PTSD reflects that the Veteran reported that he retired in 2009 with 41 years as a fork lift operator/ projection worker. The Veteran reported that he had a stroke in 2008, which left him weak, and he decided to retire at the age of 62. The VA examiner indicated that the Veteran retired in 2009 following a stroke and some physical issues related to that. The VA examiner noted that, despite PTSD symptoms, the Veteran was actively volunteering at two different places. The VA examiner opined that, given the Veteran's history and presentation, his PTSD symptoms do not render him unable to secure and maintain substantially gainful employment. A report of a VA audiology evaluation dated in October 2012 addressed the impacts of the Veteran's service-connected hearing loss and tinnitus on his employability. The Veteran reported that hearing loss impacted his ability to work because he could not hear well in background noise situations. The Veteran did not report any impact of his service-connected tinnitus on his ability to work. The Board finds that the weight of the evidence of does not demonstrate that the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, and a TDIU is not warranted. The Board acknowledges the Veteran's contention that his service-connected PTSD with secondary depression renders him unemployable. However, the weight of the competent and probative medical evidence of record does not support a findings of unemployability due to service-connected PTSD. The August 2008 VA examination reflects that some isolation due to PTSD was noted, but the Veteran was maintaining a functional role in the company he worked for. The October 2012 VA examination reflects a medical opinion that the Veteran was not unemployable due to PTSD, based on his history and PTSD symptoms. Significantly, no clinician has opined that the Veteran is unemployable due to service-connected disabilities. The evidence of record shows that the Veteran was employed until 2009, and consistently reported that he retired because of physical problems after a stroke. For these reasons, the Board finds that the weight of the credible evidence demonstrates that the criteria for TDIU have not been met or more nearly approximated for any period. As the preponderance of the evidence is against this claim, the benefit of the doubt rule is not for application, and the Board must deny the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER A rating in excess of 50 percent for PTSD with secondary depression is denied. A TDIU is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs