Citation Nr: 1335879 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 07-24 502A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to August 17, 2012. 2. Entitlement to a rating in excess of 70 percent for PTSD from August 17, 2012. 3. Entitlement to service connection for a gastrointestinal (GI) disability. 4. Entitlement to service connection for a right shoulder disability. 5. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Ogilvie, Counsel INTRODUCTION The Veteran served on active duty from September 1969 to June 1971. This case is before the Board of Veterans' Appeals (Board) on appeal from January 2006, March 2007, and January 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. A RO hearing was held before a Decision Review Officer in July 2008. A Board hearing was also held before the undersigned in July 2010. Transcripts of both hearings are of record. At the Board hearing, the Veteran submitted additional evidence with a waiver of initial Agency of Original Jurisdiction (AOJ) consideration of such evidence. In June 2012, the claims were remanded for further development. While on remand, the AOJ granted an increased rating for the Veteran's PTSD, assigning a 70 percent rating, effective August 17, 2012. Although the RO has granted a higher rating during the pendency of the appeal for the Veteran's PTSD, inasmuch as higher ratings for this disability are available both before and after August 17, 2012, and the Veteran is presumed to seek the maximum available benefit for a disability, the first two matters set forth on the title page represent the current issues on appeal regarding PTSD. See AB v. Brown, 6 Vet. App. 35, 38 (1993). At an August 2012 VA examination, the examiner noted that the Veteran had "extreme difficulty in adapting to stressful circumstances (including work or a work[-]like setting)." The Board finds that a claim of entitlement to a TDIU has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, is part of a claim for increased compensation). Under Rice, the Board has jurisdiction over the Veteran's TDIU claim and, for the purpose of clarity, has separately captioned the issue on the first page of this decision. FINDINGS OF FACT 1. Prior to August 17, 2012, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as shown by intrusive thoughts and memories, sleep disturbances, panic attacks, suicidal ideation, anger, and social isolation. 2. Since August 17, 2012, the Veteran's PTSD has not been manifested by total occupational and social impairment. 3. The evidence is in relative equipoise as to whether the Veteran's current GI disability, diagnosed as a duodenal ulcer, is causally related to his active military service. 4. The Veteran's current right shoulder disability did not manifest during his military service and is not otherwise related to an event or injury in service. 5. The Veteran's service-connected PTSD does not render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. For the rating period prior to August 17, 2012, the criteria for a 70 percent disability rating for PTSD were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. For the rating period since August 17, 2012, the criteria for a disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). 3. Service connection for a GI disability, variously diagnosed as duodenal ulcer, gastroesophageal reflux disease, and peptic ulcer disease, is warranted. 38 U.S.C.A. §§ 1110, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 4. Service connection for a right shoulder disability is not warranted. 38 U.S.C.A. §§ 1110, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 5. The criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2013). The VCAA notice requirements apply to all five elements of a claim: Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini v. Principi, 18 Vet. App. 112 (2004). 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. Regarding the Veteran's claim for service connection for a GI disability, as the Board is herein granting this claim, no further discussion of VA's duties to notify and assist will be discussed. In a November 2005 letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for service connection for a right shoulder disability, as well as what information and evidence must be submitted by him, and what information and evidence would be obtained by VA. A post-rating August 2008 letter contained information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess. The claim was readjudicated in January 2010 and February 2013. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (noting that a timing error may be cured by a new VCAA notification followed by a readjudication of the claim.). In a November 2006 letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for an increased rating for PTSD, as well as what information and evidence must be submitted by him, and what information and evidence would be obtained by VA. This letter also contained information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess. The rating decision, issued in March 2007, represents the initial adjudication following issuance of this notice. As such, the July 2006 letter meets both the content of notice and the VCAA's timing of notice requirements. All relevant evidence necessary for an equitable resolution of the Veteran's claims has also been identified and obtained. The evidence of record includes VA and private outpatient treatment records, reports of multiple VA examinations, statements from the Veteran, and the transcripts of a July 2008 RO hearing and a July 2010 hearing before the undersigned. The Veteran and his representative have not identified any other outstanding relevant evidence. The Veteran was afforded VA examinations to assess the severity of his PTSD in March 2007 and August 2012. The reports of these examinations are adequate for rating purposes as they reflect the examiners interviewed and examined the Veteran, reviewed the claims file, and reported the clinical findings in detail. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran was not afforded a VA examination to assess the nature and etiology of his right shoulder disability. VA is obliged to provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent/recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(c)(4)(i) (2013). Here, the Veteran has not met the third element. The Veteran alleges that he developed a right shoulder disability in basic training when he injured his shoulder doing pushups. The Veteran also has a current diagnosed right shoulder disability. The evidence, however, does not indicate that this right shoulder disability may be due to service. The Veteran developed pain in the right shoulder in 1989 and the early-1990s due to heavy lifting at work. In treatment records around that time, he often described a history of pain for several weeks or months. There is simply no indication that the Veteran's right shoulder symptoms may be related to service. As such, the third McLendon element has not been satisfied, and an examination is not required. The Veteran was provided an opportunity to set forth his contentions on the issues on appeal during the July 2010 hearing before the undersigned. The United States Court of Appeals for Veterans Claims (Court) has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a Veterans Law Judge has a duty to explain fully the issues and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the July 2010 hearing the undersigned explained the issues, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. The Board also notes that the case was remanded in June 2012 to obtain VA records and provide the Veteran with an examination for his PTSD. On remand, as noted above, the Veteran was afforded a VA examination in August 2012 and the appropriate records were obtained. The AOJ was also instructed to obtain records relating to the Veteran's Workers' Compensation claim for a right shoulder disability filed in the early 1990s. In correspondence dated in June 2012, the AOJ requested that the Veteran provide a completed VA Form 21-4142 to identify the relevant records and to authorize VA to obtain these records on his behalf. The Veteran did not respond to this request. In order for VA to process claims, individuals applying for VA benefits have a responsibility to cooperate with the agency in the gathering of the evidence necessary to establish allowance of benefits. See Morris v. Derwinski, 1 Vet. App. 260, 264 (1991). As the Veteran failed to respond to the AOJ's request for information regarding the records from his Workers' Compensation claim, the Board finds that VA has no further duty to assist in this regard. The Board finds that there was substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Evaluation of PTSD The Veteran filed a claim for a rating in excess of 50 percent for service-connected PTSD in August 2006. In a March 2007 rating decision, the RO continued the Veteran's 50 percent rating for PTSD. In a December 2012 rating decision, the RO increased the evaluation of PTSD to 70 percent, effective August 17, 2012. The Veteran maintains that a higher rating is warranted for each rating period on appeal. Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2013). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). For the period prior to August 17, 2012, Veteran's PTSD was evaluated as 50 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411. The next highest rating of 70 percent is assigned for PTSD under Diagnostic Code 9411 where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. In addition to service-connected PTSD, the medical evidence reflects diagnoses of personality disorder with prominent avoidant and schizoid features, pain disorder associated with both psychological factors and a general medical condition, dysthymic disorder, and major depressive disorder. Where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In this case, the Board has considered all of the Veteran's psychiatric symptoms in evaluating his service-connected PTSD. After reviewing the medical and lay evidence of record, the Board finds that the Veteran's PTSD symptoms are congruent with the criteria for a 70 percent rating outlined above, for the entire rating period on appeal (to include the period prior to August 17, 2012). The record reflects that the Veteran has had several periods of suicidal ideation, and he was hospitalized in May 2007 after endorsing suicidal ideation without intent or plan. During this time, the Veteran endorsed symptoms of lack of pleasure and decreased motivation with possible symptoms of panic. On VA examination in March 2007, the Veteran stated that he had homicidal thoughts, revealing that "sometimes [he does]" have thoughts of wanting to hurt someone. He had fair impulse control, and described violent tendencies, although episodes of violence were not found. Panic attacks occurred once or twice per week, lasting up to an hour. While the VA examiner found that the Veteran's PTSD symptoms were mild to moderate, she noted that the symptoms of all his psychiatric disorders were "interrelated and cannot be separated out." At his July 2008 RO hearing, the Veteran testified that since his hospitalization in May he felt his symptoms had worsened; he described a greater amount of suicidal thoughts, although he still denied a specific plan. Id. at 6-7. The Veteran's PTSD symptoms have significantly affected his ability to maintain personal relationships inside and outside of the workplace. On March 2007 VA examination, Veteran reported several failed marriages and a distant relationship with his sons. He also reported only having one friend, and described a fight with a co-worker in 2006. At the RO hearing in July 2008, the Veteran testified that he retired in November 2007, and since that time he used church as his only social outlet. See RO Hearing Tr. at 4. The Veteran also testified that he was unable to continue in group therapy because he "got tired of listening to people brag about their [exploits during the war]." Id. at 5. Notably, in his August 2012 VA examination, the examiner found that the Veteran had experienced an increase in his level of social and occupational functioning impairment because of recurrent suicidal ideation, periods of neglect of personal appearance, extreme difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships (with only one current social outlet at church, but disconnected from family and other people). Notably, the majority of these increased symptoms began as early as May 2007. As such, the Board finds that a 70 percent rating is also appropriate for the rating period prior to August 17, 2012. Given the extent of the Veteran's intrusive thoughts and memories, sleep disturbances, panic attacks, suicidal ideation, anger, and social isolation, the criteria for a 70 percent disability rating for PTSD have been satisfied for the period prior to August 17, 2012. The Veteran's PTSD symptoms do not, however, warrant the assignment of an even higher 100 percent rating, for either rating period on appeal. A 100 percent rating is assigned for PTSD under Diagnostic Code 9411 where there is 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. Although the Veteran's PTSD is productive of occupational and social impairment, such impairment is not total as required for a 100 percent rating. The record reflects the Veteran was able to sustain steady employment with the same employer for 23 years until his retirement in November 2007. See March 2007 VA Social Work Survey; Board Hearing Tr. at 14. While he had limited social outlets, the Veteran still went to church. See, e.g., RO Hearing Tr. at 4; August 2012 VA examination report. There is no indication that the Veteran suffers from gross impairment in thought processes or communication. There have been no reports of record of any disorientation or severe memory loss. At the August 2012 VA examination, the Veteran denied past and current hallucinations, but he did state that he felt that people were watching him the woods. The examiner, however, felt that there was no major evidence of delusional thought process. Although the Veteran had several periods of suicidal ideation to include a hospitalization, as well as severe irritability and anger, he has not been in persistent danger of hurting himself or others. Rather, the Veteran mostly experienced suicidal ideation without plan or intent. The Veteran's Global Assessment of Functioning (GAF) scores have ranged from 40 (at August 2012 VA examination) to 65 (at March 2007 VA examination). GAF scores in this range are consistent with mild to major impairment in social and occupational functioning and are reflective of social and occupational impairment most congruent with a 70 percent rating. See American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 46-47 (4th ed. 1994). In short, although the Veteran's PTSD is productive of occupational and social impairment consistent with a 70 percent rating, the criteria for a 100 percent rating not been shown for either rating period on appeal. The Board has considered whether staged ratings are appropriate. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Board finds that the Veteran's PSTD symptoms have been consistent with a 70 percent rating for the entire relevant time period here on appeal. The Veteran's key PTSD symptoms-particularly his intrusive thoughts and memories, sleep disturbances, panic attacks, suicidal ideation, anger, and social isolation-have been longstanding in nature, and the record does not indicate any significant increase or decrease in such symptoms during the appeal period. Moreover, as explained above, symptoms warranting a 100 percent rating have not been shown. Accordingly, staged ratings are not warranted and the 70 percent rating the Board has assigned is appropriate for the entire period here on appeal. The Board has also considered whether referral for an extraschedular rating is appropriate. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (2013). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of Compensation Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Veteran's PTSD symptoms primarily involve intrusive thoughts and memories, sleep disturbances, panic attacks, suicidal ideation, anger, and social isolation. Such impairment is specifically contemplated by the rating criteria and the Veteran has been evaluated on that basis. Hence, the rating criteria reasonably describe the Veteran's disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's PTSD would be in excess of that contemplated by the ratings assigned above; the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). In summary, the evidence supports a rating of 70 percent, and no higher, for the Veteran's PTSD. To that extent, the appeal is granted for the rating period prior to August 17, 2012. The Board has also considered whether a TDIU rating is warranted. Initially, it is noted that there is no prejudice to the Veteran in the Board deciding this aspect of the appeal as a claim for a TDIU was implicitly denied by the AOJ. See Rice, 22 Vet. App. at 453-55; Adams v. Shinseki, 568 F.3d 956, 961-64 (Fed. Cir. 2009) (finding that in certain circumstances, a claim for benefits will be deemed to have been denied, and thus finally adjudicated, even if VA did not expressly address that claim in its decision). Through a Rating Decision, Statement of the Case, and Supplemental Statements of the Case, the AOJ has decided that no more than a 50 percent disability rating is warranted for PTSD (prior to August 17, 2012) and no more than a 70 percent disability rating is warranted for PTSD (from August 17, 2012). These decisions were sufficiently clear to put the Veteran on notice that a total rating was being denied. A TDIU rating may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or 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. 38 C.F.R. § 4.16(a) (2013). As a result of the Board's decision to increase the Veteran's rating for PTSD to 70 percent throughout the appeal period, he meets the schedular criteria for TDIU under 38 C.F.R. § 4.16(a). While the Veteran is currently service connected for a GI disability, type II diabetes mellitus, and PTSD, only his PTSD has been raised as affecting his work. Entitlement to TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). 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). In arriving at a conclusion, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his/her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2013). Based upon a review of the record, the Board finds that the Veteran's service-connected PTSD does not render him unable to secure or follow substantially gainful employment. The Veteran retired from employment with VA in November 2007, due to back and shoulder disabilities only. See RO Hearing Tr. at 14. See also Board Hearing Tr. at 13. Prior to his retirement, the Veteran had a short period of hospitalization due to suicidal ideation, but it did not appear to significantly affect his work or render him unable to work. In discussing his hospitalization at his July 2008 RO hearing, he noted that "[i]t d[id]n't take long [for him] to get back on track, once [he was] thrown off." See RO Hearing Tr. at 6. When asked at this hearing if he would be able to return to work were he without any physical disabilities, the Veteran responded, "oh yeah." See RO Hearing Tr. at 14. See also Board Hearing Tr. at 13 (denying that his retirement had anything to do with PTSD symptoms). At an August 2012 VA examination, the examiner noted that the Veteran had "extreme difficulty in adapting to stressful circumstances (including work or a work[-]like setting)." There is no indication, however, that the Veteran's PTSD renders him unable to secure or follow substantially gainful employment. The Veteran's high disability rating for PTSD in itself is a reflection that he has occupational impairment, including difficulties in adapting to stressful circumstances in a work-like setting. Although the Veteran is retired, he has not asserted at any time that he had to retire due to his PTSD or that he would be unable to work due to his PTSD, and the evidence of record does not suggest as such. Thus, entitlement to TDIU is not appropriate in this case. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). III. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). Service connection may be granted for any disease initially diagnosed after 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) (2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2011); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Gilbert, 1 Vet. App. at 54. A. GI Disability The Veteran has alleged that his currently-diagnosed GI disability had its onset in service. With regard to current disability, on August 2012 VA examination, the Veteran was diagnosed with duodenal ulcer. He also has other diagnoses of other GI disabilities, to include gastroesophageal reflux disease (GERD) and peptic ulcer disease. The examiner noted that these diagnoses have been used interchangeably by the Veteran's providers. With regard to an in-service disease, on separation from the military in June 1971, the Veteran underwent an examination, and noted that since his last physical he had developed ulcers. The Veteran's service treatment records also reflect that he required a refill of an antacid prescription (Titralac) in June 1971. The Veteran has stated that he was diagnosed with an ulcer during this time by a private physician. See RO Hearing Tr. at 11. Thus, the crux of the appeal is whether the Veteran's current diagnosis of duodenal ulcer is causally related to his in-service complaints and self-reported diagnosis of ulcers. The Veteran has asserted that he has suffered from GI symptoms since service, and he is competent to testify regarding his ongoing symptomatology. See 38 C.F.R. § 3.159(a)(2) (2013); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board also finds the Veteran credible in his testimony, which is bolstered by his consistent self-reported history regarding the onset of his disability. See, e.g., June 1975 insurance form (reporting a duodenal ulcer in 1971, and identifying the private physician who made the diagnosis). The record also reflects that the Veteran has continued to complain of and seek treatment for GI-related symptomatology since separation from service. Post-service, in August 1971, the Veteran underwent an upper GI series, which was negative for a duodenal ulcer and otherwise normal. In December 1973, the Veteran was diagnosed with chronic peptic ulcer disease. In March 1976, the Veteran underwent an upper GI series which revealed a chronic duodenal ulcer. The Veteran underwent VA examination in August 2012, where the examiner diagnosed the Veteran with a duodenal ulcer. He noted that the original date of the diagnosis was in 1971. After an examination of the Veteran, he noted that the Veteran's various diagnoses of GERD, peptic ulcer disease, and duodenal ulcer, were all used interchangeably by the providers. The examiner then stated that the Veteran "no more likely than not still has and has had a [d]uodenal ulcer as his civilain [sic] doctor diagnosed in the early 1970s." As this statement was confusing, VA requested an addendum opinion. In January 2013, a physician reviewed the claims filed and noted that the Veteran had a diagnosis of peptic ulcer disease in 1973 and GERD in 1997. He found that it was less likely than not that peptic ulcer disease was caused by or a result of military service. As rationale, he noted that the Veteran's GI diagnoses were established after military service was completed. As the physician providing the January 2013 addendum opinion failed to consider the in-service notation of "ulsers" [sic] on the Veteran's separation examination, as well as the his credible reports of continuing symptomatology since service (substantiated by treatment records), the Board finds this addendum opinion to be inadequate and affords it no probative weight. See generally Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (A VA examination is inadequate where it ignores the claimant's statement of in-service incurrence.). After consideration of all evidence of record, the Board finds that the Veteran's claim of entitlement to service connection for a GI disability should be granted. The evidence has consistently shown that the Veteran first experienced GI symptoms in service and was diagnosed with a duodenal ulcer in or around 1971. Although subsequent to service, a GI series revealed normal results, the Veteran has suffered from GI symptoms since separation. Notably, at his August 2012 VA examination, the examiner noted that the onset of his duodenal ulcer was in 1971, and that the Veteran "still has and has had" a duodenal ulcer as his civilian doctor diagnosed it in the 1970's. This statement is consistent with the medical and lay evidence of record and appears to weigh in favor of the claim. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Thus, given the facts noted above, and with resolution of all reasonable doubt in the Veteran's favor, the Board concludes that the criteria of entitlement to service connection for a GI disability have been met. B. Right Shoulder Disability The Veteran has alleged that he injured his right shoulder during exercises performed in basic training. The Veteran has a currently-diagnosed right shoulder disability of impingement syndrome. See December 2011 VA operative note. Regarding the Veteran's alleged in-service injury, the Veteran alleges that while in basic training in 1969, he felt something pop in his right shoulder when he was doing pushups. See Board Hearing Tr. at 3. At his Board hearing, the Veteran testified that he received treatment at sick call and was given a profile to prevent him from doing pushups. Id. at 4. He testified that he sought treatment from a private physician in 1971, and since his injury, his shoulder has remained symptomatic. Id. at 5-6. Service treatment records are silent for any complaints of right shoulder pain or injury. At separation, the Veteran's upper extremities were found to be normal, and he specifically noted that the only problem since his previous medical examination was the onset of ulcers. Immediately after separation, the Veteran filed a claim for compensation with VA for ulcers only. On VA examination in August 1971, the Veteran also reported ringing in the ears and left eye problems, but there was no mention of any right shoulder pain. The Veteran's musculoskeletal system was found to be normal. Regarding the Veteran's claims of in-service injury to his right shoulder and continuous symptomatology since his injury, a layperson is competent to report on matters observed or within his or her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Veteran is also competent to testify about observable symptoms or injury residuals. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, the Veteran is competent to report a continuity of symptomatology. See Charles v. Principi, 16 Vet. App. 370 (2002). While the Veteran is competent to report on his injury and symptoms, however, the Board does not find his reports to be credible as they internally conflict with the medical evidence of record. While the Board recognizes the absence of in-service documentation of an injury is not by itself detrimental to the Veteran's claim, the medical evidence from this time contradicts the Veteran's statements that he suffered an injury to his right shoulder has remained symptomatic ever since. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but it cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.). In this regard, the Veteran's upper extremities were marked as normal at separation. Further, the Veteran specifically noted that he was suffering from ulcers at the time of his separation, but he did not mention his right shoulder. Immediately subsequent to separation, the Veteran filed a compensation claim with VA for ulcers, but did not seek compensation for any right shoulder injury. On VA examination in August 1971, the Veteran's musculoskeletal system was found to be negative, and he never mentioned any right shoulder problems. At his Board hearing, the Veteran testified that he sought treatment for problems related to his in-service right shoulder injury from a private physician in 1971. Board Hearing Tr. at 6. In fact, the record is silent for right shoulder complaints until July 1989, when the Veteran sought treatment in conjunction with a Workers' Compensation claim regarding right shoulder pain as a result of heavy lifting at work. Testing, X-rays, and MRI were normal at that time. In July 1992, the Veteran complained of a three-week history of pain over the superomedial border of his right scapula. He denied a history of trauma. He was diagnosed with rhomboid strain and pain. In August 1992, the Veteran mentioned his intention to file another work-related injury claim regarding his shoulder. On examination in September 1992, the Veteran reported right shoulder pain spontaneously beginning about three to four months prior. He reported no history of neck or shoulder injury including shoulder dislocation. The Veteran was diagnosed with right shoulder strain. The Board finds that the Veteran's present statements of in-service right shoulder injury and continuing right shoulder symptomatology lack credibility. If the Veteran's right shoulder was still bothering him to the extent that he was seeking private treatment in 1971, it seems unreasonable that he would fail to mention it in his VA examination for benefits or report it at separation, as he did another ongoing problem. More importantly, in 1989 and in the early-1990s when the Veteran was pursuing treatment and his Workers' Compensation claim, he often reported that he had suffered from right shoulder pain for weeks and months-not decades as he testified at his Board hearing. He also denied a history of shoulder injury on several occasions. The Board places greater probative weight on the statements that the Veteran made in conjunction with treatment. Statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. White v. Illinois, 502 U.S. 346, 355-56 (1991); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate). The evidence of record fails to indicate that the Veteran's current right shoulder disability is related to his service. Accordingly, service connection for a right shoulder disability is not warranted. ORDER For the rating period prior to August 17, 2012, a rating of 70 percent, but no higher, is granted for PTSD, subject to controlling regulations applicable to the payment of monetary benefits. From August 17, 2012, entitlement to a rating in excess of 70 percent for PTSD is denied. Entitlement to service connection for a GI disability, variously diagnosed as duodenal ulcer, GERD, and peptic ulcer disease, is granted. Entitlement to service connection for a right shoulder disability is denied. Entitlement to TDIU is denied. ____________________________________________ Donnie R. Hachey Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs