Citation Nr: 1335863 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 07-34 321 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), rated as 30 percent disabling prior to November 2, 2009; 50 percent disabling from November 2, 2009 to March 23, 2011 and 70 percent disabling from March 23, 2011 to November 2, 2011. 2. Entitlement to a total rating based upon individual employability (TDIU) due to service-connected disability. 3. Entitlement to service connection for shingles, to include as secondary to service-connected PTSD. 4. Entitlement to service connection for diverticulosis, to include as secondary to service-connected PTSD. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from March 1968 to March 1969. This appeal to the Board of Veterans' Appeals (Board) arises from a December 2006 rating decision in which the RO, inter alia, continued the 30 percent rating assigned for PTSD (in June 2006), denied entitlement to a TDIU and denied service connection for diverticulosis and shingles. In August 2009, the Veteran testified during a Board hearing (Videoconference) before the undersigned Veterans Law Judge; a transcript of that hearing is of record. As the Veteran disagreed with the initial rating assigned following the grant of service connection for PTSD, the Board has characterized this issue in light of Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). In November 2009 and again in August 2011, the Board remanded the claims on appeal to the RO, via the Appeals Management Center (AMC) in Washington, D.C., for further development. After completing additional development, the AMC continued to deny each claim (as reflected in a November 2012 supplemental statement of the case (SSOC)), and returned these matters to the Board for further appellate consideration. In a November 2012 rating decision, the AMC partially granted the Veteran's claim for an higher initial rating for PTSD, and awarded a 50 percent rating from November 2, 2009 to March 23, 2011, a 70 percent rating from March 23, 2011 to November 2, 2011 and a 100 percent rating beginning on November 2, 2011. As the Veteran was not granted the full benefit sought for the period prior to November 2, 2011, the issue that remains before the Board is whether the Veteran is entitled to an increased rating prior to November 2, 2011. See AB v. Brown, 6 Vet. App. 35 (1993) (a Veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals additional adjudicatory documents, including a September 2013 Informal Hearing Presentation submitted by the Veteran's representative. The Board's decisions as to the claims for an increased rating for PTSD, entitlement to a TDIU and service connection for shingles are set forth below. The remaining claim on appeal is addressed in the remand following the order; this matter is being remanded to the RO, via the AMC, in Washington, D.C. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. The Veteran's psychiatric symptoms have included nightmares, concentration difficulties, isolation, the avoidance of people, depression, anxiety, poor grooming, intrusive thoughts, feelings of detachment, hallucinations, impaired judgment and subjective reports of memory difficulties; collectively, these symptoms are indicative of no more than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. For the period prior to November 2, 2011, service-connected PTSD was rated as 70 percent disabling, and the Veteran's combined rating was 70 percent. 4. The Veteran was gainfully employment prior to February 16, 2006. 5. For the period beginning on February 16, 2006, the Veteran met the percentage requirements for award of a schedular TDIU, and the overall evidence suggested that his service-connected disability precluded substantially gainful employment consistent with his educational and occupational background. 6. Although a post-service notation of shingles is reflected in the record, medical evidence does not clearly establish that the Veteran actually meets the criteria for a diagnosis of shingles. 7. Medical evidence of record does not support a finding that there exists a medical relationship between any current shingles disability and either the Veteran's military service or his service-connected PTSD. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent for PTSD for the period prior to November 2, 2011 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for the award of a TDIU rating by reason of service-connected PTSD, beginning on February 16, 2006, are met. 38 U.S.C.A. §§ 501, 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.340, 3.341, 4.16, 4.19, 4.25 (2012). 3. The criteria for service connection for shingles are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a November 2005 pre-rating letter provided notice to the Veteran regarding the information and evidence needed to substantiate what was then a claim for service connection for PTSD. In addition, a June 2006 pre-rating letter provided such notice regarding the information and evidence needed to substantiate a claim for service connection for shingles on a direct basis while a December 2009 post-rating letter provided such notice with regards to a claim for service connection for shingles on a secondary basis. A July 2006 letter provided such notice regards to the claim for TDIU. These letters also informed the Veteran of what information and evidence must be submitted by him, and what information and evidence would be obtained by VA. The December 2006 rating decision reflects the RO's initial adjudication of the claims for service connection for PTSD and shingles, as well as the claim for TDIU, after the issuance of the November 2005, June 2006 and July 2006 letters. After issuance of the December 2009 letter, and opportunity for the Veteran to respond, in March 2011, the RO issued a SSOC which reflects readjudication of the Veteran's claim for service connection for shingles. Hence, the Veteran is not shown to be prejudiced by the timing of this December 2009 letter. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed be readjudication of the claim, such as in a statement of the case or supplemental statement of the case is sufficient to cure a timing defect). After the award of service connection, and the RO's receipt of the Veteran's disagreement with the assigned rating, a letter dated in August 2008 set forth the criteria for higher ratings for psychiatric disabilities (the timing and form of which suffices, in part, for Dingess/Hartman). In addition, the June and July 2006 letters provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates with regard to the claim for service connection for shingles, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. Moreover, the Board notes that there has been no allegation of prejudice from any notice deficiency. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the reports of the VA examinations, as well as the Veteran's VA outpatient treatment records, various private treatment records and Social Security Administration (SSA) records (requested by the Board in its November 2009 and August 2011 remands), and various private treatment records. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Also of record and considered in connection with the appeal are various written statements provided by the Veteran, his representative and his friend. As regards the Board hearing in August 2009, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the August 2009 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal. Also, information was solicited regarding the Veteran's current psychiatric symptoms and his past employment history. The Veteran explicitly declined to testify regarding his claimed shingles. In addition, the record was held open for an additional 30 days to allow for the submission of additional evidence. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2), and that Board hearing was legally sufficient. The Board also finds that no additional RO action to further develop the record in connection with claims decided herein, prior to appellate consideration, is required. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran was notified and made aware of the evidence needed to substantiate these claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeals. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Rating for PTSD A. Factual Background A report of a July 2005 private psychiatric evaluation notes the Veteran's complaints of nightmares, fatigue, concentration difficulties, isolation, the avoidance of people, depression and intrusive thoughts. He reported having no hobbies and that "nothing in life is fun for him." Mental status examination noted that the Veteran's grooming was not "very good" and that his appearance was unkempt and disheveled. He was noted to have difficulty maintaining eye contact and expressing himself on subjects which were "bothering him." Concentration was found to be extremely impaired, memory was found to be globally intact, affect was found to be flat, judgment was found to be impaired, orientation was found to be intact and mood was found to be depressed, bland, sad and tearful. Speech was circuitous and tearful. Depressive symptomology was found to include a depressed mood, anergia, anhedonia, a constriction of interests, isolation and a sleep pattern disturbance. There was no delusion system or thought disorder present. A GAF of 30 was assigned. A report of a September 2006 VA examination reflects the Veteran's complaints of isolation at home, a lack of interest in doing things, being easily distracted, nightmares, feelings of detachment, a depressed mood and hopelessness. Memory difficulties-including forgetting where he was, that he did not go anywhere alone, that he did not keep up with his medication independently-were reported. Mental status examination found him to be clean and appropriately and casually dressed. Speech was found to be unremarkable, affect was found to be normal, mood was found to be depressed and he was found to be intact to person, time and place. Thought process and thought content were found to be unremarkable. There were no homicidal or suicidal thoughts and he was noted to have the ability to maintain minimum personal hygiene. A GAF of 52 was assigned. In a March 2007 statement, the Veteran's friend describes the Veteran's decline in functioning. She indicated that she had met the Veteran while doing business and that he had been active, had a great memory and was one of her "toughest customers to sell because he did his job." She detailed his recent symptoms, including a lack of energy and interest in previously enjoyable recreational activities, forgetfulness and increased frustration. An April 2007 private psychological evaluation notes the Veteran's symptoms of depression, poor memory, confusion, social avoidance, being readily startled and the avoidance of any sort of situation that might call for a confrontation. He reported receiving a "great deal" of help with bathing, grooming, dressing and personal hygiene. Mental status examination found his emotional range to be somewhat constricted and his thought processes to be digressive but responsive to inquiries. A GAF of 60 was assigned. In a June 2008, the Veteran underwent a VA psychosocial assessment. He reported that he went into an orphanage at age 6, that he lived there with his five siblings until he graduated high school, was physically abused in this home and that he had been married three times. A history of attempting to hurt himself or inpatient treatment were denied. Mental status examination found the Veteran to be casually and appropriately dressed, mood to be depressed, affect to be calm, memory to be intact and speech to be of normal, volume and rhythm. Thought processes were found to be linear and goal directed with some evidence of paranoia. Although he reported auditory or visual hallucinations, he did not appear to be psychotic. Suicidal or homicidal ideations, intents or plans were denied. A GAF of 50 was assigned. A July 2008 private treatment note reflects the Veteran's complaints of nightmares, anxiety, isolation, the avoidance of crowds and the avoidance of situations where there was any type of physical or emotional closeness. Mental status examination found memory to be very vivid for some of the in-service events, affect was found to be distant, judgment was found to be impaired, orientation was found to be intact and mood was found to be blunted, bland and depressed. Grooming was noted to not be "very good" and his appearance was noted to be unkempt. Difficulties with concentration or maintaining eye contact were also found. A GAF of 30 was assigned. A July 2008 VA treatment note reflects the Veteran's complaints of nightmares, sleeping about four hours per night, night sweats, anxiety, irritability, memory loss, flashbacks and intrusive thoughts. He reported that he was married to his third wife, that he had one child from a previous marriage and that he had not worked in three years. Suicidal and homicidal ideations were denied. Mental status examination found mood to be depressed, affect was found to be flat, memory was found to be intact and processes were found to be normal while judgment, insight and impulse control were found to be fair. There were no hallucinations found. A GAF of 55 was assigned. An August 2008 VA treatment note indicates that the Veteran was alert and fully oriented but disgruntled. Speech was found to be coherent, hygiene was found to be generally intact and insight and judgment were found to be in fair control. Affect was found to be constricted and mood was found to be frustrated/angry and tense. A GAF of 53 was assigned. A December 2008 VA treatment note lists the Veteran's symptoms as ongoing bad dreams, anxiety and stressors and noted that he had problems with his marriage. Mood was found to be sullen and affect was found to be blunted. Current suicidal and homicidal ideations were not found. A GAF of 51 was assigned. A February 2009 VA treatment note reflects the Veteran's complaints of ongoing problems with anxiety, nightmares and sleep disturbances. Mood was found to be anxious and depressed while affect was found to be blunted. A GAF of 52 was assigned. Mental status examination conducted in May 2009 found the Veteran to be alert, attentive and oriented. He was found to be casually groomed and his speech was found to be of a normal tone, volume and rhythm. Thought processes were found to be goal-directed with no evidence of a formal thought disorder, delusions or paranoia. Mood was found to be dysphonic, affect was found to be full and congruent, executive functioning was found to be "probably" intact and abstract thinking was found to be intact. Insight was found to be superficial and judgment was found to be fair. Problem solving capacity was found to not be impaired. Active suicidal or homicidal ideations, intents or plans were denied. A GAF of 50 was assigned. A July 2009 private psychiatric treatment note reflects the Veteran's reports of problematic sleep with very intense, vivid and difficult to manage dreams. Mental status examination noted that the Veteran's grooming was "not very good" and unkempt and concentration was found to be very difficult while memory was found to be vivid and intense in some situations but absent for others. Affect was found to be distant, judgment was found to be impaired, orientation was found to be intact and mood was found to be blunted, bland and severely depressed. The provider noted that the Veteran was isolated and had severe concentration impairments, a sleep pattern disturbance due to nightmares and severe interpersonal relationship problems. A GAF of 30 was assigned. During an August 2009 hearing, the Veteran testified that his current psychiatric symptoms included frequent nightmares, night sweats, trouble with concentration, isolation and irritability towards his family, wife and friends. He described his home life as difficult and stated that his wife was supportive in some ways and "irritated" in other ways. A November 2, 2009 private treatment note reflects the Veteran's complaints of difficulty concentrating, flashbacks that interfered with his sleep and that helicopter activity near his home triggered very violent flashbacks and nightmares. Other complaints included isolation as he did not feel comfortable around other people, depression and the avoidance of violent movies or television shows as they triggered nightmares. Mental status examination found his concentration to be markedly impaired while memory was found to be intense and vivid for situations that happened during service. Affect was found to be distant, judgment was found to be impaired, orientation was found to be intact and mood was found to be blunted, bland and depressed. The Veteran's grooming was found to not be "very good" and he was somewhat "unkempt in appearance." A GAF of 30 was assigned. A June 2010 private treatment note reflects the Veteran's complaints of severe problems falling asleep, that he was sleeping about three to four hours a night, a lack of energy, depression and concentration problems. He reported hallucinations of flashbacks from his service in Vietnam. Mental status examination found the Veteran's mood to be depressed, agitated, irritated and fearful. Affect was found to be flat, speech was found to be of normal rate, rhythm and volume and his appearance was noted to be unkempt. He appeared to be oriented, attention span was found to be satisfactory and memory for remote events was found to be accurate. A GAF of 40 was assigned. A July 2010 private treatment note reflects the Veteran's reports of "bad" dreams and difficulties sleeping. Suicidal and homicidal ideations were denied. An August 2010 private treatment note indicates that the Veteran was still having "bad dreams," night sweats and depression. Suicidal and homicidal ideations were denied. A second August 2010 private treatment note indicates that the Veteran's flashbacks were getting "more intense" and that he continued to deny suicidal and homicidal ideations. A March 22, 2011 private treatment note reflects the Veteran's complaints of flashbacks of Vietnam, crying episodes and problems with short and long term memory. Suicidal and homicidal ideations were denied. A May 2011 private treatment note reflects the Veteran's reports of continued nightmares and hallucinations as well as unspecified memory problems, flashbacks and crying episodes. A second May 2011 private treatment note indicated that the Veteran was still seeing people and events from the past along with smells, and dead bodies. B. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A 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). Where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of 'staged rating' (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. The RO assigned the initial rating for the Veteran's PTSD under Diagnostic Code 9411. However, psychiatric disabilities other than eating disorders are actually rated pursuant to the criteria of a General Rating Formula. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. Psychiatric examinations frequently include assignment of a GAF score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness". There is no question that 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). Considering the pertinent evidence in light of the above, the Board finds that, with resolution of all reasonable doubt in the Veteran's favor, an initial 70 percent but no higher rating for PTSD is warranted from the August 2005 effective date of the award of service connection. The pertinent evidence includes the contemporaneous mental health records, the various VA examinations and private evaluations and the Veteran's hearing testimony. The record establishes that the Veteran has experienced such psychiatric symptoms as nightmares, concentration difficulties, isolation, avoidance of people, depression, anxiety, intrusive thoughts, feelings of detachment, hallucinations, impaired judgment, subjective reports of intermittent memory difficulties and poor grooming. Collectively, these symptoms have resulted in occupational and social impairment in most areas of the Veteran's life, thus indicating a moderately severe disability picture. The Veteran's psychiatric impairment has been characterized by symptomatology which suggests moderate to severe social impairment. He has reported being unable to establish or maintain friendships, that he had no hobbies and that he avoided interacting with people. He did maintain a relationship with his current wife, however, the records suggests that this relationship was strained. A March 2007 letter from the Veteran's friend indicated that they no longer engaged in various recreational activities and that the Veteran no longer socialized with her. The Veteran was not employed and did not attend school during the course of the appeal. The above-cited evidence demonstrates that the Veteran's PTSD has been characterized by hallucinations and impaired judgment, symptoms associated with a 70 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Such evidence also demonstrates, in the Board's opinion, the Veteran's inability to establish and maintain effective relationships. Id. As previously noted, the Veteran does not have any social relationships outside of his wife and his adult child. In addition, the relationship with his wife has been strained throughout the appeal, as he reported problems with his marriage in December 2008 and that he was irritable with his wife in August 2009. A July 2009 private treatment note indicates that the Veteran experienced "severe interpersonal relationship problems" but did not detail the nature of these problems. Hallucinations were reported on numerous occasions and judgment was found to be impaired or fair in July 2005, July 2008, August 2008, July 2009 and November 2009. The Board further finds that the GAFs assigned in this case are consistent with no more than the 70 percent rating herein assigned. As noted, the Veteran has been assigned GAF scores that have ranged wildly from 30 to 60, with most scores falling in the 50 to 55 range. Under the DSM-IV, GAF scores ranging from 61 to 70 are indicative of some mild symptoms (like depressed mood and mild insomnia), or some difficulty in social, occupational or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Scores from 51 to 60 are indicative of 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 peers or co-workers). Scores ranging from 41 to 50 are indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Collectively, the assigned scores are indicative of mild to serious symptoms under the DSM-IV guidelines. As noted, however, assigned GAF scores are not dispositive of the evaluation issue but must be considered in light of the actual symptoms; the objective findings regarding the Veteran's symptoms do not support a finding of mild impairment. See 38 C.F.R. § 4.126(a). Private psychological evaluations conducted in July 2005, July 2008 and July 2009 contained an assigned GAF score of 30, the lowest score assigned during the appellate period, suggesting serious symptoms or serious impairments in social, occupational or school functioning; the 70 percent rating herein assigned contemplates such serious symptoms or serious impairments. Moreover, the assigned GAF scores between 50 and 55 reflect less impairment than that contemplated by the 70 percent rating herein assigned; as such, it clearly provides no basis for an even higher rating. Accordingly, the collective evidence supports a finding that, since the award of service connection in August 2005, the Veteran's PTSD has been characterized by symptomatology which results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, consistent with a 70 percent disability rating. With respect to whether the Veteran's PTSD warrants the maximum 100 percent disability rating at any time prior to November 2, 2011, the Board observes that the evidence does not demonstrate symptomatology which is more suggestive of total occupational and social impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In this regard, none of the contemporaneous records or examination reports reflect any gross impairment in thought process or communication and the Veteran's memory was found to be intact or not impaired on objective examination despite the Veteran's subjective reports of memory difficulties. Although his appearance was noted to be unkempt or disheveled on several occasions, he was noted to be clean and appropriately dressed on several occasions, including in September 2006 and June 2008, and there is no indication that he was unable to minimal personal hygiene. Moreover, the September 2006 VA examiner found that he was able to maintain minimal personal hygiene. In addition, total social impairment was not demonstrated as he maintained a relationship with his wife and his adult child. Although hallucinations were reported, such symptoms were not demonstrated on objective examination and there is no suggestion that such hallucinations were persistent. Suicidal and homicidal ideations were consistently denied and the Veteran has not been found to be a persistent danger to others despite his reports of irritability. Therefore, a maximum, 100 percent rating is not warranted for any period pertinent to this appeal. See 38 C.F.R. § 4.130. Accordingly, the collective evidence supports a finding that, during the instant appellate period, the Veteran's PTSD has been characterized by symptomatology which results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, consistent with a 70 percent disability rating. The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds at no point pertinent to the appellate period has the Veteran's PTSD been shown to be so exceptional or unusual to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule 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" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, 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 extra-schedular rating. Thun, 22 Vet. App. 111. In this case, the Board finds that schedular criteria are adequate to rate the Veteran's PTSD at all times pertinent to this appeal. As discussed above, the Veteran's predominant subjective and objective psychiatric symptoms impact his overall social and occupational functioning. A comparison between the Veteran's symptoms and the criteria of the rating schedule indicates that the rating criteria reasonably describe his level of impairment. Further, as noted, the rating schedule provides a higher rating based on evidence demonstrating more severe impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds an initial 70 percent rating for PTSD, but no higher rating, for the appellate period prior to November 2, 2011, is warranted. The Board has applied the benefit-of-the-doubt doctrine in awarding the initial 70 percent rating, but finds that the preponderance of the evidence is against assignment of the maximum, 100 percent rating at any time prior to November 2, 2011. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-53 (1990). C. TDIU The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran is in receipt of service-connected compensation benefits for PTSD only. For the period prior to November 2, 2011, the Veteran has been awarded a 70 percent rating. A November 2011 rating decision awarded a 100 percent rating for PTSD, effective November 2, 2011. The Veteran contends, in essence, that a TDIU should be awarded prior to the assignment of the 100 schedular rating, going back to the date of service connection for PTSD in August 2005. A TDIU rating is assigned, where the schedular rating is less than total, when service-connected disabilities result in such impairment of mind or body that the average person is so disabled that he is precluded from following a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be at least 70 percent. 38 C.F.R. § 4.16(a). Under 38 C.F.R. § 4.16(a), the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability are met and in the judgment of the rating agency such service-connected disability renders the Veteran unemployable. Here, for the period in question, service connection was in effect for PTSD, rated as 70 percent disabling. Thus, for the period in question, the percentage requirements of 38 C.F.R. § 4.16(a) clearly were met. 38 C.F.R. § 4.25, 4.26. Thus, the remaining question is whether, for this time frame, the Veteran's service-connected disability rendered him unable to obtain to obtain or retain substantially gainful employment. The central inquiry is whether a veteran's service-connected disabilities, alone, are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). With regard to the instant claim, the Board notes the decision in Bradley v. Peake, 22 Vet. App. 280 (2008) in which the Court held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation under 38 U.S.C.A. § 1114(s). Thus, the Court reasoned, it might benefit the Veteran to retain or obtain the TDIU rating even where a 100 percent schedular rating has also been granted. Bradley, at 293-94. Because of this holding, VA's General Counsel withdrew VAOPGCPREC 6-99, which was contrary to the holding of Bradley. See 75 Fed. Reg. 11229 -04 (March 10, 2010). Hence, the matter of the Veteran's entitlement to a TDIU remains on appeal. See Bradley, supra. The record indicates that the Veteran worked as a quality control supervisor in a furniture factory for 15 years and that he had completed four years of college. In a May 2006 examination report, the Veteran reported that he had worked as a furniture technician for forty years. First, the record indicates that the Veteran stopped working in December 2005. In a VA Application for Increased Compensation Based on Individual Unemployability (VA From 21-8940), the Veteran indicated that he stopped working in December 2005. He further reported that he last worked "five months ago" in a March 2006 VA examination report. However, the July 2009 SSA decision found that the Veteran last worked on February 15, 2006 and the Veteran indicated in his SSA application that he became unable to work due to his conditions, and stopped working, on February 15, 2006. Therefore, TDIU cannot be awarded for the period prior to February 15, 2006 as the record establishes that the Veteran maintained employment. Turning to the question of whether the Veteran's service-connected PTSD renders him unemployable, the Board notes that record contains several opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The first set of these opinions are reflected in September 2006 and February 2011 VA examination reports. The September 2006 examiner opined that the Veteran's psychiatric symptoms would create moderate difficulty in maintaining physical or sedentary employment, particularly in his field of engineering, but would not preclude all employment. A February 2011 VA examiner opined that the Veteran's PTSD would create "significant, serious difficulty" in maintaining functional employment in either a physical or sedentary capacity but would not preclude employment. In addition, the Board notes that the Veteran reported that he had quit working due to his health in a May 2006 VA examination report. The second set of these opinions are reflected in a July 2005 private psychiatric evaluation and a November 2011 VA examination report. The private provider opined in a February 2005 evaluation that the Veteran was unable to maintain employment due to his PTSD symptomatology, including his difficulties concentrating, marked interpersonal relationship problems and depression. In a July 2009 treatment note, this provider further noted that the Veteran's unemployability was "permanent in nature." In November 2011, a VA examiner opined that it was at least as likely as not that the Veteran would be unemployable secondary to his PTSD in most typical full-time job settings due to the severity of his symptoms, including difficulties concentrating and focusing attention as well as depression. The Board also notes an April 2007 private psychiatric evaluation found that while the Veteran's long tenure in employment suggested that his relationship with peers, coworkers and supervisors was "probably adequate," his tolerance for common workplace stresses was greatly reduced. In addition, the Veteran has been awarded SSA benefits in July 2009 based, at least in part, on his mood disorder. Given the evidence and the medical opinions already of record, the Board concludes that the evidence is, at least, in relative equipoise on the unemployability question. Accordingly, further evidentiary development is not necessary. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (noting that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). When, as here, after consideration of all evidence and material of record in a case for VA benefits, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. With resolution of all reasonable doubt in the Veteran's favor, the Board finds that assignment of a TDIU, by reason of the service-connected PTSD, is warranted for the period beginning on February 15, 2006; accordingly, the appeal is granted. III. Service Connection The Veteran generally contends that his shingles were caused or aggravated by his service-connected PTSD; he has provided no argument as to direct service connection. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection on a direct basis, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Certain chronic diseases shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service (one year for diabetes mellitus), even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Shingles is not listed as a chronic disease under 38 C.F.R. § 3.309(a). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Here, service treatment records do not reflect any treatment, complaints or diagnoses related to shingles. A January 1968 service entrance examination and an October 1969 service discharge examination were negative for treatments, complaints or diagnoses related to singles. In an October 1969 Report of Medical History, the Veteran indicated that he did not have any illness or injury other than those already noted in the report. Similarly, service personnel records did not reflect any treatments, complaints or diagnoses related to shingles. The post-service clinical evidence documents the Veteran's reports of pain from shingles in a March 2011 private psychiatric treatment note. The Veteran denied a history of shingles in a March 2006 VA treatment note; however, he reported a history of shingles in a January 2007 private treatment note. In a June 2010 private psychological evaluation, a history of repeated shingles was reported by the Veteran and contained an Axis III notation of shingles. At the outset, the Board notes that the evidence does not clearly establish that the Veteran actually meets he diagnostic criteria for shingles. As indicated, the Veteran reported a history of shingles in January 2007 and that he was suffering from pain related to shingles in March 2011. Although the June 2010 private psychological evaluation contained an Axis III notation of shingles, such does not constitute a diagnosis of shingles. See, e.g., Hildoer v. Nicholson, 24 Vet. App. 196 (2007), citing DSM-IV ("Axis III" refers to general medical conditions that are potentially related to the understanding or management of the individual's mental disorder in the context of an examination for mental disorders). Thus, without a medical evidence of a current disability related to shingles within the meaning of McClain, fundamentally, there can be no award of service connection on any basis. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, supra. Moreover, even if the Board was to assume, arguendo, that the collective medical evidence--to include the Axis III notation of shingles and the Veteran's reports of pain as a result of shingles--provides competent evidence as to the existence of the currently claimed disability, the claim would still have to be denied on the basis of medical nexus to service. The Board points out that none of the medical records referencing shingles includes any medical comment or opinion that there exists a medical nexus between any current shingles and either the Veteran's military service or service-connected PTSD. Significantly, neither the Veteran nor his representative has presented or identified any existing medical evidence or opinion that, in fact, supports the claim. Generally, VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, while the Veteran may have demonstrated that he has a current disability related to shingles, but there is nothing to indicate that the disability may be associated with an event, injury, or disease in service or to a service-connected disability. As previously discussed, the Veteran himself does not contend that he experienced any symptoms related to the claimed disability during service or for many decades after service. Additionally, there is no medical or other persuasive evidence which suggests that any current shingles are related to service or a service-connected disorder. Therefore, VA has no obligation to obtain any medical opinion(s) commenting upon the etiology of the Veteran's claimed shingles. See 38 U.S.C.A. § 5103A(d); 3.159(c)(4); McLendon, 20 Vet. App. at 83. As for the lay assertions of record, the Board notes that the Veteran is certainly competent to report his own symptoms or matters within his personal knowledge. See Jandreau, supra; Buchanan, supra. In addition, laypersons may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that 'a valid medical opinion' was required to establish nexus, and that a layperson was 'not competent' to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, matters of medical diagnosis for disability and nexus are not capable of lay observation (and, if competently shown, a medical relationship between such disability and service)-such as the one here at issue-are matters within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran is not shown to be other than a layperson without appropriate medical training and expertise to competently self-diagnose shingles, to render a diagnosis as to a current disability related to shingles, or to opine as to the etiology of any such disability, the lay assertions in this regard have no probative value. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998). For all the foregoing reasons, the Board finds that service connection for shingles must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER An initial 70 percent rating for PTSD for prior November 2, 2011 is granted, subject to the legal authority governing the payment of VA compensation. The claim for a TDIU is granted as of February 16, 2006, subject to the legal authority governing the payment of VA compensation. Service connection for shingles, to include as secondary to service-connected PTSD, is denied. REMAND The Board's review of the claims file reveals that further RO action on the remaining claim for service connection for diverticulosis on appeal are warranted. With regards to the claim for service connection for diverticulosis, the Board's August 2011 remand directives instructed that a VA examination was to be conducted to determine its etiology. Specifically, the examiner was to determine whether the diverticulosis was incurred in or aggravated by service or, in the alternative, whether it was caused or aggravated by his service-connected PTSD. Such an opinion was obtained in November 2011. The examiner provided an opinion as to both direct and secondary service connection, noting that the exact etiology of diverticulosis was not known. However, in September 2013, the Veteran's representative submitted multiple articles and extracts which detailed the effects of PTSD, including its impact on the gastrointestinal system. The Veteran's representative has also argued that the VA's own research supports the contention that PTSD aggravated the claimed disability. Accordingly, the RO should forward the claims file to the examiner who had evaluated the Veteran in November 2011 and completed the accompanying examination report for an addendum opinion. The RO should only arrange for further examination of the Veteran if the prior examiner is unavailable or if further examination of the Veteran is deemed necessary. The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of the claim for service connection (as the original claim will be considered on the basis of the evidence of record). See 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to the scheduled examination, the RO should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. While this matter is on remand, to ensure that the record is complete, and that all due process requirements are met, the RO should undertake appropriate action to ensure that all outstanding, pertinent records are associated with the claims file. As for VA records, the claims file reflects that the Veteran has been receiving treatment for his various disabilities from the VA Medical Center (VAMC) in Salisbury and that records from that facility dated through February 2009 are associated with the file; however, more recent records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Hence, the RO should obtain all records of pertinent treatment from the Salisbury VAMC (since February 2009) for the Veteran, following the current procedures prescribed in 38 C.F.R. § 3.159(c) with regard to requests for records from Federal facilities. The RO should also give the Veteran another opportunity to provide information and/or evidence pertinent to the claims remaining on appeal. The RO's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1); but see also 38 U.S.C.A. § 5103(b)(3) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims on appeal. The RO's adjudication of the claim should include consideration of all additional evidence added to the record since the last adjudication of the claim. Accordingly, the matter is REMANDED for the following action: 1. Obtain from the Salisbury VAMC all outstanding, pertinent records of evaluation and/or treatment of the Veteran related to any gastrointestinal disability, including diverticulosis, dated since February 2009. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claim on appeal that is not currently of record. Also clearly explain to the Veteran that he had a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, forward the entire claims file, to include a complete copy of this REMAND, along with copies of relevant Virtual VA records, to the examiner who provided the November 2011 opinion for an addendum opinion. For diagnosed diverticulosis, the examiner should render an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability (a) was incurred in or aggravated by active service; or if not (b) was caused or is aggravated by service-connected PTSD. If aggravation of a nonservice-connected condition by a service-connected disability is found, the examining physician should attempt to quantify the degree of additional disability resulting from such aggravation. The examiner should specifically address the Veteran's contention that his service-connected PTSD caused or aggravated his diverticulosis. This consideration should include the documents submitted or referenced by the Veteran's representative in its September 2013 Informal Hearing Presentation. In rendering the requested opinion, the examiner should specifically consider and discuss the service treatment records and post-service treatment records. If the examiner who provided the November 2011 opinion is no longer employed by VA or is otherwise unavailable, or another examination of the Veteran is deemed warranted, that fact should be documented in the claims file, arrange for the Veteran to undergo another VA examination, by an appropriate physician, at a VA medical facility, to obtain an opinion responsive to the question and comments noted above. In such instance, the entire claims file, to include a complete copy of this REMAND, and copies of any pertinent Virtual VA records, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All indicated tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The physician should set forth all examination findings (if any), along with the complete rationale for the conclusions reached, in a printed (typewritten) report. 5. If the Veteran fails to report to any scheduled examination, obtain and associate with the claims file (a) copy(ies) of any notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. 6. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 7. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the claim remaining on appeal in light of all pertinent evidence (to include any evidence received since the October 2012 SSOC) and legal authority. 8. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs