Citation Nr: 1329880 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 12-23 595 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD S. Nathanson, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1966 to August 1968. These matters came before the Board of Veterans' Appeals (Board) from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The symptoms of the Veteran's PTSD have most nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. The Veteran's service-connected disabilities have not rendered him unable to obtain and retain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.16, 4.18, 4.19, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Assist and Notify The Veterans Clams Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The claims arise from the Veteran's disagreement with a rating assigned in connection with the grant of service connection for PTSD. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to 'downstream' questions, the claim has been substantiated and there is no need to provide additional VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Board notes, however, that the AMC sent the Veteran a September 2010 letter that complied with the VCAA's notification requirements and a June 2011 letter that explained how to establish entitlement to TDIU. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records and post service treatment records have been obtained. The Veteran alleges he sought treatment from L.G., a physiological counselor. The only treatment records from L.G. include an evaluation dated in October 2010 from an evaluation conducted in September 2010, and a letter from September 2011 which indicates the Veteran sought an evaluation from L.G. in September 2010. VA requested all treatment records from L.G. in September or October 2010, and, in June 2011 and September 2011 VCAA notice letters, VA requested the Veteran submit any outstanding treatment records related to his PTSD. VA subsequently requested any outstanding treatment records from L.G. in September 2011. The Veteran also indicated upon VA examination in March 2011 that all pertinent treatment records were already of record. The Veteran was afforded a VA examination in March 2011. As described below, this examination is adequate as it is based on consideration of the Veteran's prior medical history, and described his PTSD disability in sufficient detail to enable the Board to make a fully informed evaluation of this disability. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was not afforded an examination regarding his claim for a TDIU. The determination of individual unemployability is a legal determination and not a medical matter. See Moore v. Nicholson, 21 Vet.App. 211, 218 (2007), rev'd on other grounds sub nom. Moore v. Shinseki, 555 F.3d 1369 (Fed.Cir.2009) ("The medical examiner provides a disability evaluation and the rating specialist interprets medical reports in order to match the rating with the disability"). As such, the Board need not obtain an opinion specifically addressing the legal issue of whether the Veteran is individually unemployable. For reasons stated below, the evidence of record is sufficient to adjudicate the claim . See Id. (noting that it is the duty of VA adjudicators, not medical examiners, to apply the appropriate legal standard). The Board does not have notice of any additional relevant evidence which is available but has not been obtained. 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). Legal Principles Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Separate ratings may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the evidence establishes that the disability has not significantly changed and a uniform evaluation is warranted. The Veteran is in receipt of a 30 percent rating for PTSD pursuant to 38 C.F.R. § 4.130, DC 9411. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 30 percent rating requires a showing of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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. A total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The GAF (Global Assessment of Functioning) scale reflects psychological, social, and occupational functioning of a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A score of 31 to 40 is assigned where there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but that the individual is generally functioning pretty well and has some meaningful interpersonal relationships. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association, 1994. The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Analysis In this case, while fluctuations in symptomatology, GAF scores, and overall impairment are present during the course of the appeal period, the Board finds that the overall symptomatology and level of impairment have most nearly approximated those indicative of a 30 percent rating, and consequently, a 50 percent or greater disability rating is not warranted. In this regard, the evidence shows that PTSD was diagnosed in September 2010. At that time, the Veteran was examined by L.G., a psychological counselor. According to L.G., the Veteran described severe sleep problems, avoidance of conversation about his military service, hypervigilance, exaggerated startled response, and problems with memory and concentration. He further reported that since returning from service, he has a shorter fuse, drinks heavily to forget his combat experiences, cannot tolerate having people behind him, does not socialize, and prefers to spend time alone. L.G. noted the Veteran was cooperative and dressed normal. His affect was restricted and had a dysthymic mood. He was without current suicidal or homicidal ideation. L.G. expressed that the Veteran's symptoms interfered significantly in his personal, social, and professional life. She further noted that the Veteran's hypervigilance and isolating behaviors compromised his ability to initiate or sustain work or social relationships. His prognosis for recovery was deemed poor. L.G. found that the Veteran was permanently and totally disabled and unemployable. A GAF score of 37 was rendered. On VA examination in March 2011, the Veteran's history was reviewed. The Veteran reported that he thinks about his deployment, but not all of the time and tries not to dwell on the memories. He endorsed recurrent and distressing recollections of his combat experiences less than weekly and noted that he thinks about his service more as he grows older. The Veteran also complained of chronic sleep impairment with distressing dreams approximately two times a month. He noted he will scream in his sleep and will wake up looking for danger. The Veteran noted that funerals and television shows about the military trigger memories of Vietnam which cause him mild distress. He indicated he tries to stay busy to avoid thinking about his experiences and will only talk to people who were in the military about his combat experiences. In regard to family and social relationships, the Veteran reported he has a good relationship with his wife of 43 years and his grandchildren. He confides in his wife about most things, they enjoy going out to eat together, and he described that they are compatible and good friends. He has a few good friends who are also veterans and, although not socially active, he is still close with someone from his own service. The Veteran indicated he enjoys fishing and watching games. He also works around the house and helps his neighbor when needed. He indicated that he does not socialize with many other couples, avoids crowds, does not like having his back to people, and feels the need to stay alert and watch out for potential problems that would affect him and his wife. He also noted several exaggerated startled responses within the last month. The Veteran further indicated that it is difficult to express love and compassion and he has a hard time feeling sadness when people pass away. In regard to the Veteran's employment, he retired due to old age in 2009 after working as a service technician for a telephone company for 41 years. He generally had satisfactory work performance, but lost interest and productivity in his last five years of working. He generally worked alone, but stated he got along well with others. The Veteran also noted some problems with concentration and memory. Upon psychological examination, the Veteran reported he has no history of suicide or suicidal thoughts, no history of violence or homicidal thoughts, and does not use alcohol or any other substance. He denied having delusional thoughts, hallucinations, obsessive or ritualistic behavior, or panic attacks. The examiner described the Veteran as appropriately dressed with unremarkable psychomotor activity and speech. The Veteran's attitude was appropriate and cooperative. The examiner noted the Veteran's mood was good. The Veteran's attention was intact and was oriented to time, place, and purpose. He showed normal thought processes and no impaired judgment or impaired abstract thinking. The examiner noted the Veteran partially understands that he has a problem and generally tends to minimize his problems. The examiner opined that the Veteran's symptoms are mild and rendered a GAF score of 65. The examiner further opined that the Veteran did not have total occupational impairment due to PTSD signs and symptoms, did not have deficiencies in judgment, thinking, family relations, work, or mood, and did not have reduced reliability and productivity due to his PTSD. The examiner did note that the Veteran had occasional decreases in work efficiency with intermittent periods of inability to perform occupational tasks due to his PTSD, but had generally satisfactory functioning. The Veteran reported in a June 2011 claim for TDIU that he has problems sleeping due to dreams and flash backs, problems with is memory and concentration, difficulty focusing long enough to finish tasks, and that he cannot adjust to crowds. A September 2011 letter from L.G. reflects the Veteran continues to suffer from nightmares and chronic sleep impairment. She reported the Veteran has more intrusive thoughts about his time in the military now that he is retired, he is easily distracted, and he has a hard time finishing projects. She further noted he avoids socializing, family gatherings, and feels estranged from civilians. The March 2011 VA medical opinion is found to be of greater probative weight than the evaluation from L.G. because it contains an explanation of the reasons for the conclusion based on an accurate review of the pertinent evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). See also Stefl v. Nicholson, 21 Vet. App. 120, 123, 124-25 (2007) (a medical examiner must support his conclusion with an analysis that is adequate for the Board to consider and weigh against contrary opinions; a medical opinion is considered adequate where it is based on consideration of the Veteran's prior medical history and examinations and also describes the disability, in sufficient detail to allow the Board's evaluation to be a fully informed one). The Board notes that it may favor the opinion of one competent medical professional over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Veteran contends in a June 2011 notice of disagreement that the evaluation from L.G. should be afforded greater probative weight than the VA examination. The Board notes that the fact that a veteran has received treatment from a physician or other doctor is a consideration in determining the credibility of that doctor's opinions and conclusions. That notwithstanding, the Court has declined to adapt a "treating physician rule" under which a treating physician's opinion would presumptively be given greater weight than that of a VA examiner or another doctor. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998); Guerrieri v. Brown, 4 Vet. App. 467, 471-3 (1993). Unlike in the examination report by L.G., the March 2011 VA examiner provided a well-reasoned rationale based on the Veteran's contentions and medical history for assessing the severity of the Veteran's symptoms. L.G. determined the Veteran had a GAF score of 37 and found him to be totally and permanently disabled. L.G. is competent to enter a GAF score, to include one of 37. However, L.G.'s clinical findings are wildly inconsistent with what is expected from a GAF of 37. See Richard v. Brown, 9 Vet. App. 266 (1996). The evidence or record does not reflect, nor does the Veteran allege, that he has any impairment in reality testing or communication. The Veteran denied delusions, hallucinations, and suicidal ideations at the March 2011 VA examination. The evidence also does not support that the Veteran suffers from major impairment in several areas of his life. As above, he has a good relationship with his wife of over 40 years, he had a stable job for over 40 years from which he retired due to age, and there is no evidence of record to indicate the Veteran's judgment is impaired. There are also inconsistencies between the September 2010 evaluation by L.G. and March 2011 VA examination report. L.G. reported that the Veteran avoids conversation about his military service; however, upon examination in March 2011, the Veteran stated he is able to speak about Vietnam with other veterans. L.G. also reported that the Veteran "drank heavily to try to forget his combat experiences" while the Veteran denied alcohol use and/or substance abuse in March 2011. L.G. indicated that the Veteran does not socialize; however, the Veteran stated upon examination in March 2011 that he goes out to eat with his wife, spends time with his grandchildren, and has some good friends who are also veterans. L.G. described the Veteran's affect as restricted and mood as dysthymic while the VA examiner found the Veteran's affect as normal and mood to be good. In regard to the Veteran's contentions in L.G.'s evaluation that he suffers from traumatic nightmares, hypervigilance, problems with memory and concentration, exaggerated startle response, and avoidance of crowds, those statements have been considered and found to be probative as they are consistent with the evidence of record. The Board notes that, although the June 2011 notice of disagreement indicates the VA examiner only spoke with the Veteran for 30 to 40 minutes, the examination report provides that the examiner reviewed the Veteran's medical record for 30 minutes, reviewed the claims file for 90 minutes, and evaluated the Veteran for 90 minutes. Based on the above, the evidence demonstrates that the Veteran's PTSD has been productive of symptomatology resulting in occasional occupational and social impairment manifested as chronic sleep impairment, hypervigilance, anxiety, suspiciousness, and problems with concentration. The evidence demonstrates he is able to maintain social and familial relationships, specifically with his wife, with whom he can confide and considers a good friend, and his grandchildren. He maintained stable employment for over 40 years with satisfactory work performance and an ability to get along well with others. He also continues to go fishing, watch games, do work around the house, and help his neighbor as needed. Although the Veteran reported that he thinks about his time in Vietnam more frequently, has experienced problems with concentration, has chronic sleep impairment, and avoids crowds, these symptoms are contemplated in a disability rating of 30 percent and he also indicated that when he becomes distressed he keeps himself busy by doing projects around his house. While not minimizing the Veteran's PTSD symptomatology, the record indicates he has normal affect and speech, no panic attacks, no difficulty understanding complex commands, no impairment in judgment or abstract thinking, a good mood, and an ability to establish some effective social and occupational relationships. Even accepting L.G.'s observation that the Veteran had a restricted affect, the VA examiner described the Veteran's affect as normal. The Veteran's restricted affect, therefore, is at most intermittent. Another symptom the Veteran experiences is some impairment in memory and concentration. Although the Veteran has not been shown to satisfy most of the criteria for a 50 percent rating, he is not required to. Rather, what is required is that the evidence shows that he suffers symptoms or effects that also cause occupational or social impairment with reduced reliability and productivity. The evidence above shows that he does not have occupational or social impairment with reduced reliability and productivity and more closely approximate the criteria for a 30 percent disability rating. The criteria for the next higher rating of 50 percent have therefore not been met or approximated for any period in this appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Consideration has also been given to a rating of 70 percent and 100 percent for the Veteran's PTSD, but the Board finds that such a rating is not warranted. The Veteran denied suicidal or homicidal ideation. Moreover, the Veteran does not show symptoms such as obsessive 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; spatial disorientation; neglect of personal appearance and hygiene; or an inability to establish and maintain effective relationships. Also, the evidence does not show that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a 70 percent or 100 percent rating. Mauerhan , 16 Vet. App. at 442-43. The Board has considered the lay evidence and pleadings. However, the pleadings are generally legal arguments about how to weigh the evidence. In regard to the other lay evidence, such evidence is competent and generally credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, there are some conflicts as to the extent of the symptoms and the Board find his report to the VA examiner to be more probative and credible as it is more consistent with the clinical findings. Extraschedular Consideration As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that both the symptoms of the Veteran's PTSD and his overall impairment are fully contemplated by the applicable rating criteria, and the Board's analysis explained why this warranted a 30 percent rating under the relevant criteria. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. In any event, the Veteran did not claim, and the probative evidence does not reflect, that there has been marked interference with employment or frequent hospitalization from his PTSD or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of an extraschedular rating for PTSD is not warranted. 38 C.F.R. § 3.321(b)(1). For the foregoing reasons, the preponderance of the evidence is against the claim for a rating higher than 30 percent for PTSD. The benefit-of-the-doubt doctrine is therefore not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). TDIU The Veteran contends in his June 2011 application for increased compensation based on unemployability that he cannot work because he has problems sleeping due to dreams and flash backs as well as problems with memory, concentration, and focusing long enough to finish tasks. He further contends he is startled easy and cannot adjust to crowds. The RO denied the Veteran's claim in a July 2012 statement of the case. Total disability ratings for compensation based on TDIU may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of (1) a single service-connected disability ratable at 60 percent or more, or (2) as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a)(2). Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by non service- connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, the Veteran is service connected for PTSD rated at 30 percent, diabetes mellitus with erectile dysfunction due to exposure to agent orange rated at 20 percent, status post left knee injury with degenerative joint disease rated at 10 percent, status post right knee injury with degenerative joint disease rated at 10 percent, residuals of shrapnel wound of right leg, with retained foreign bodies rated at 0 percent, and scar, right knee associated with residuals of shrapnel wound of right leg, with retained foreign bodies rated at 0 percent. The Veteran has a combined disability rating of 60 percent. 38 C.F.R. §§ 4.16(a), 4.25. All of the Veteran's disabilities arise from injuries or diseases he incurred as result of his combat in Vietnam, including exposure to agent orange. Thus, under a broad interpretation of 38 C.F.R. § 4.16(a), the Veteran's disabilities are treated as one disability as they all result from a common etiology and/or as multiple injuries incurred in action. The combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) are met. Consequently, the Board must determine whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). In this case, the evidence of record showes that the Veteran is not precluded from securing or following a substantially gainful occupation as a result of his service-connected disabilities. The Veteran is a 66 year old high school educated male. Upon VA examination in October 2008 and March 2011, he reported that he worked at a telephone company for over 40 years as a telephone line installer and repairman. He indicated that he retired in 2009 because of his age and generally had satisfactory work performance while employed. He noted that within his last five years of employment he started to lose interest and focus and may have had one warning concerning his performance. While the private medical opinion from L.G. opined that the Veteran's PTSD alone renders him unemployable, the Board has found that this report and her opinion that he is totally and permanently disabled is of little probative value, as discussed in greater detail above. Moreover, the opinion expressed by L.G. concerning the Veteran's employability is contradicted by the opinion expressed in the March 2011 VA examination report. In the March 2011 VA examination report, which as described above is of greater probative weight, the VA examiner determined that the Veteran experiences only an occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks, but generally has satisfactory functioning. The VA examiner considered, among other things, the Veteran's complaints of memory loss, problems with concentration, chronic sleep impairment, and his avoidance of crowds in her opinion. In addition, the other evidence of record supports the conclusion that the Veteran's service-connected disabilities do not significantly interfere with his employment. The Veteran was afforded a diabetes mellitus examination and joints examination in October 2008. The examiner noted that the Veteran has been employed as a telephone line installer and repairman for a telephone company for 40 years. He opined that neither disability significantly interfered with his ability to work. In regard to the diabetes mellitus, the examiner reasoned, "he has missed no days of work. The veteran is still able to perform his job...The diabetes mellitus condition showed no effect on his occupational function...[and] his diabetes mellitus condition showed no effect on his daily activities except his erectile dysfunction." In regard to the knee condition, the examiner reasoned that, "the veteran is still able to perform his job...[T]he bilateral knee condition shows no significant affect on this occupational functions; although the veteran experienced worsening knee pain at the end of the day." This evidence reflects that the Veteran's service connected disabilities to not render him unemployable. While these examinations were conducted in October 2008, the Veteran has not indicated that these disabilities have increased in severity since the 2008 examinations. Therefore, the Board finds that the examinations accurately depict the current severity of the Veteran's symptoms and their corresponding impact on his employability. Accordingly, the preponderance of the evidence is against the Veteran's claim of entitlement to TDIU, and this claim must be denied. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). ORDER A disability rating in excess of 30 percent for service-connected PTSD is denied. Entitlement to a TDIU is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs