Citation Nr: 1337272 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 11-17 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for right ear hearing loss disability. 2. Entitlement to service connection for left ear hearing loss disability. 3. Entitlement to an increased initial rating for posttraumatic stress disorder (PTSD), rated 30 percent from March 9, 2010, to December 20, 2011, and rated 50 percent 50 percent as of December 21, 2011. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD A. Lech, Associate Counsel INTRODUCTION The Veteran had active service from March 1967 to March 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, that granted service connection for PTSD and assigned a 30 percent rating, effective March 9, 2010. A March 2012 rating decision assigned a 50 percent rating, effective December 21, 2011. However, as that grant does not represent a total grant of benefits sought on appeal, this claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In connection with this appeal the Veteran testified at a hearing before the Decision Review Officer (DRO) at the RO in Waco, Texas in November 2011. A transcript of the hearing is associated with the claims file. The Veteran was also scheduled to testify before the Board at a hearing at the VA RO in August 2012. The Veteran did not appear at the scheduled hearing, and did not provide good cause for not appearing. Therefore, his hearing request is deemed to have been withdrawn. The Board has reviewed the physical claims file and the Virtual VA electronic claims file. The issue of entitlement to service connection for left ear hearing disability is REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's PTSD has been manifested by occupational and social impairment that more nearly approximates reduced reliability and productivity. 2. Right ear hearing loss disability is related to acoustic trauma sustained in active service. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 50 percent, but not higher, for PTSD for the entire period on appeal, are met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. Right ear hearing loss disability was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA will assist a claimant in obtaining evidence necessary to substantiate a claim, but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. VA must notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary, that is necessary to substantiate the claim. As part of the notice, VA has to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), 38 C.F.R. § 3.159 (2013). The notice to a claimant should be provided at the time that, or immediately after, VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record shows that the Veteran was mailed a letter in April 2010 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. The April 2010 letter also provided the Veteran with appropriate notice with respect to the disability rating and effective date elements. The Board also finds the Veteran has been provided adequate assistance in response to his claim. The Veteran's service medical records and VA treatment records and examinations are of record. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any outstanding evidence. Therefore, the duties to assist and notify have been met. Increased Rating for PTSD The Veteran seeks an initial increased rating for PTSD. The RO granted service connection for PTSD in a September 2010 rating decision and assigned a 30 percent rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, effective March 9, 2010. The Veteran appealed that decision, and the RO granted a 50 percent disability rating effective December 21, 2011. When an appellant seeks an increased rating, it will generally be presumed that the maximum benefit allowed by law and regulation is sought. A.B. v. Brown, 6 Vet. App. 35 (1993). Therefore, the claim for an increased initial rating remains on appeal. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. 38 C.F.R. § 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 conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(a), 4.1 (2013). If two ratings are potentially applicable, 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. § 4.1 (2013). After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient. Above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013). The Veteran's entire history is reviewed when assigning a rating. 38 C.F.R. § 4.1 (2013). Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Veteran is appealing the initial assignment of a disability rating. Therfore, the severity of the disability is to be considered during the entire period from the initial assignment of the evaluation to the present time. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. PTSD is rated under Diagnostic Code 9411. That diagnostic code uses the General Rating Formula for Mental Disorders, which provides that a 30 percent rating is warranted for a mental disorder if it is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 50 percent rating is warranted for a mental disorder when there is 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; and difficulty in establishing effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 70 percent rating is warranted for a mental disorder when 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 work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 100 percent rating is warranted for a mental disorder when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130 , Diagnostic Code 9411 (2011). In rating psychiatric disabilities, VA has adopted the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association (DSM-IV). That manual includes a Global Assessment of Functioning (GAF) scale which takes into consideration psychological, social and occupational functioning on a hypothetical continuum of mental illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996). A score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). A score of 51 to60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A score of 61 to 70 represents mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., Washington, D.C., American Psychiatric Association (1994). The evidence for consideration in this case includes VA examination reports, VA treatment records, and lay testimony and statements. This appeal stems from the initial grant of service connection. The Veteran has not challenged the March 2010 effective date for the grant of service connection, and therefore, the relevant question is the state of disability beginning in March 2010. 38 C.F.R. § 3.400 (2013). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim to disability or death benefits. 38 U.S.C.A. § 1154(a) (West 2002). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by VA. VA shall consider all information and lay and medical evidence of record with respect to benefits under laws administered by VA. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has reviewed all evidence of record pertaining to the history of the service-connected PTSD. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). At a September 2010 VA examination, the examiner noted that the Veteran's combat stressors included participating in search and destroy missions, booby traps, heavy artillery, mortar fire, and sporadic gun fire. A particular stressor reported by the Veteran included the Veteran shooting the dog of a man who would not point out who was responsible for the booby trap that killed three of the Veteran's men. The examiner noted that the Veteran felt helpless, stunned, and horrified. The Veteran reported drinking up to seven beers a day in service. The examiner noted that the Veteran had worked at the post office for the past 37 years. The Veteran reported not wanting to be a manager; not being happy and being ready to retire; not getting along with management; not taking orders very well; and disliking when someone told him how to do his job. The Veteran told the examiner that the union was the only thing that prevented him from being fired over the years; that he was outspoken and yelled, and has been walked off the job a few times for that behavior; that he had never been sent to employee counseling; that he got along with his coworkers; and that he worked nights. The examiner noted that the Veteran reported getting along well with co-workers. The examiner stated that the Veteran had been married for 37 years and that was his second marriage. The Veteran reported loving his wife as much as he did when they first met, and stated that she knew his moods and knew when he wanted to be left alone. The Veteran stated that he was irritable and easily angered. He reported that he had a good relationship with their children. The Veteran reported seeing his sister on holidays and visiting his mother every week. The Veteran reported not having any close friends, but spending time with his wife's unmarried brother and sister. The Veteran reported having a couple of shots of tequila nightly; playing golf; collecting sports memorabilia; attending sports memorabilia shows; and going out to eat, see shows, and shop with his wife. The Veteran reported that he and his wife liked each other's company and gave each other space. The examiner stated that the Veteran consumed alcohol and smoked marijuana daily when he came home from Vietnam, contributing to problems at work. The Veteran reported cutting down on alcohol consumption. The Veteran reported seeking mental health treatment only in the six months prior to the VA examination, as he was raised with a "suck it up" attitude. The Veteran reported a history of fighting, the last incident having occurred ten years ago, resulting in his ejection from a sporting event. The Veteran reported one incident of suicidal intent about three years after returning home from Vietnam, but no thoughts or ideation since then. The examiner noted that the Veteran did not exhibit any impairment of thought process or communication; no hallucinations; and no inappropriate behavior. The Veteran was casually dressed, his grooming was adequate, mood agitated, affect congruent, he was initially very irritable, he made eye contact and was cooperative, and denied any suicidal or homicidal thoughts or ideation. The Veteran was able to maintain minimal personal hygiene and basic activities of daily living; he was oriented; he did not experience impaired memory; denied obsessive or ritualistic behaviors; his rate and flow of speech were within normal limits; and he reported experiencing what he thought were panic attacks (sweating and difficulty breathing). The Veteran reported feeling rather depressed weekly, not being able to sleep, tuning out his wife, experiencing guilt feelings all the time, and not being able to make decisions. He reported being anxious and worrying about his family and finances. The examiner noted that the Veteran exhibited impaired impulse control and engaged in gambling, betting large sums of money on sporting events. The Veteran reported sleeping about six hours a night, having some insomnia, and waking up frequently. He reported nightmares about every two weeks and having low energy during work hours. The Veteran worked at night. The Veteran reported being upset over a puppy he hit on the road and having to pull over because of it; having to have his back to the wall when he was out in public; being startled by slamming doors; having to re-read sections of the paper due to poor concentration; refusing to watch movies about the war; getting upset about the war in Iraq and Afghanistan; feeling separate and different from other people; routinely drinking to avoid thinking about Vietnam; getting along with Vietnamese women, but not men, at work; and helicopter sounds causing flashbacks that may last all day. The examiner diagnosed the Veteran with PTSD, assigning the Veteran a GAF score of 65. The examiner noted that the Veteran experienced recurrent intrusive images or thoughts about the trauma; recurrent distressing dreams about the trauma; acted or felt as if the event was recurring; experienced intense psychological distress at exposure to cues that resembled the traumatic event; exhibited efforts to avoid thoughts, feelings, or conversations associated with the trauma; exhibited efforts to avoid thoughts, places, or people that aroused recollections of the trauma; experienced diminished interest or participation in activities; experienced feeling of detachment or estrangement from others; had difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. The examiner noted that there was reduced reliability and productivity due to the Veteran's PTSD symptoms. At a December 2011 VA examination, the examiner confirmed a diagnosis of PTSD and assigned the Veteran a GAF score of 55. The examiner noted that the Veteran experienced stress at work, and that the Veteran's father in law passed away recently, which contributed stress to the holiday season. The examiner stated that the Veteran's depression and alcohol abuse were secondary to the PTSD and had symptoms which could be differentiated from the PTSD diagnosis. The symptoms associated with depression included guilt, hopelessness, amotivation, and social withdrawal; and the alcohol abuse likely maintained and exacerbated the conditions. The examiner opined that the Veteran experienced occupational and social impairment with reduced liability and productivity. The examiner noted that the Veteran was married and living with his wife; he golfed occasionally; went to the movies or car shows with a friend; enjoyed going out for breakfast; and spent his days off on the computer and gambling on sports games. The Veteran worked for the post office and planned to retire in a few months. He had participated in psychotherapy for a year and a half, and found therapy helpful, stating that it had helped him alleviate some of his symptoms. The examiner noted that the Veteran smoked a pack of cigarettes a day and consumed six beers a day. The examiner noted that the Veteran experienced recurrent and distressing recollections of the stressor event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event; physiological reactivity on exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event; efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that aroused recollections of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affect; difficulty falling or staying asleep; irritability or outbursts of anger; and hypervigilance. The examiner noted that the Veteran experienced symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work. The examiner stated that while the Veteran continued to experience PTSD symptoms, there had not been any significant exacerbation since his last evaluation, and that the therapy had helped him alleviate some symptoms. The examiner stated that the Veteran experienced increased stress during the holidays, and that he continued to have difficulty managing his emotions, despite his best intentions to control them. The examiner stated that the symptoms had an impact on the Veteran's work situation and his relationship with his supervisors, but that the Veteran had not been formally reprimanded recently. The Veteran told the examiner that the supervisors left him alone to do his job, and that he had held that job for 38 years. The examiner noted that the Veteran was socially withdrawn, but had been married for 38 years, and had been able to establish friendships at work with other Veterans. The examiner stated that the Veteran was independent in activities of daily living, and able to manage his finances and medication. The examiner noted that the PTSD caused the Veteran severe distress, and he suffered from guilt over his actions in service. The examiner also noted that the Veteran suffered from mild attention problems and attention-based memory problems. VA treatment records show that the Veteran has been seeking treatment for PTSD since 2010. The treating physician who initially diagnosed the Veteran with PTSD in January 2010 assigned him a GAF score of 65. The physician stated that the Veteran experienced flashbacks; recurrent unwanted and painful memories of the events in Vietnam; nightmares about his combat experiences; feelings of intense distress in response to cues that remind him of the combat experiences; avoided situations that are reminiscent of the war; attempted to push those memories out of his mind; and experienced sleeping difficulties, increased irritability, poor concentration, and an exaggerated startle response. The Veteran described no history of suicidal, violent, or assaultive behaviors. He reported having a supportive relationship with his family and friends and stated that he worked at the post office. The record also indicates that the Veteran participated in both group and individual therapy for his PTSD from May 2010 to May 2011. Progress notes show that the Veteran worked on showing more emotion, relaxation techniques, areas of distorted thinking, and decreasing his PTSD symptoms. Around February 2011, the Veteran experienced a mild increase in symptoms of PTSD and depression. Around April 2011, the Veteran exhibited a mild decrease in symptoms of PTSD and depression. The Veteran's PTSD symptoms were described as "moderate" throughout the progress notes, and he was assigned GAF scores of 50 to 55. The Veteran submitted a statement in support of his claim in May 2010. He stated that he was called names and degraded for serving his country when he came home from Vietnam. He stated that he saw good friends sent home in body bags or with serious wounds. The Veteran stated that in the years following his service, he suffered from depression and took solace in drinking and isolating himself, which took a toll on his first marriage. He stated that he did not kill himself because he thought of the friends whom he lost in the war, and considered suicide a disgrace to those who died fighting. The Veteran stated that he felt guilty having survived when others did not. The Veteran stated that he had recurring dreams of the war and of his actions, that he was uncomfortable in crowded or noisy places, and that he just wanted to be left alone. The Veteran stated that he preferred to sit with his back to the wall, did not feel comfortable expressing emotions, and found it difficult to trust others. He stated that he hated family reunions and other large groups, and that he only spoke about Vietnam to others who have served and who would understand what war was really like. In his May 2010 Stressful Incident Description, the Veteran described the circumstances under which he received a Bronze Star with the V Device. While under mortar attack providing security, the Veteran rescued a wounded soldier who fell into the river. The Veteran pulled the man to safety and covered him with his own body in an attempt to shield him from the barrage of incoming mortar rounds. The Board finds that the Veteran is entitled to a disability rating of 50 percent, but not higher, for the entire period on appeal for PTSD. The Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as 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; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. While the Veteran reported that his symptoms have improved since he commenced treatment, he also reported frequent anxiety, irritability, sleep disturbances, and hypervigilance to the examiners. While the Veteran was able to maintain a job at the post office for 38 years and he got along with his co-workers, he experienced significant conflicts with his managers due to his inability to take and follow directions and respect authority. While the Veteran was close to his wife and their children, he experienced conflicts with his wife, and regular detachment and the need to be alone. While the Veteran saw his sister on holidays and mother weekly, and spent some time with his wife's brother and sister, he reported not having any friends outside of the family. The Veteran reported liking to be alone and drinking every day, but also played golf; collected sports memorabilia; attended sports memorabilia shows; and went out with his wife. While the Veteran's judgment and thought processes were intact, his impulse control was impaired. He engaged in a physical altercation at a sporting event, and regularly engaged in gambling, betting large sums of money. The Veteran displayed a full range of affect. While the Veteran's memory was intact, he experienced mild attention problems and attention-based memory problems. While the Veteran denied suicidal or homicidal ideation, had full contact with reality, and did not experience any hallucinations, he did experience suicidal plans a few years after returning from Vietnam. The Veteran reported having recurrent nightmares about Vietnam and recurrent intrusive thoughts about it. He practiced avoidance behavior, avoiding films or news about the war, and avoiding speaking to non-Veterans about his experiences. While the Veteran experienced hypervigilance and exaggerated startle response, he was also able to maintain personal hygiene and had no problems with everyday activities. The Veteran was able to manage his distress by going to sit in the car and practicing relaxation techniques. The September examiner assigned the Veteran a GAF score of 65. While that score indicated that the Veteran experienced mild impairment, the Board notes that the examiner stated that the Veteran's symptoms overall resulted in reduced reliability and productivity. That score was also inconsistent with the intensity and severity of symptoms reported in the examination report. The physician who initially diagnosed the Veteran with PTSD in January 2010 assigned him a GAF score of 65. Again, that score was inconsistent with the intensity and severity of symptoms reported in the examination report. The VAMC treating physician repeatedly assigned the Veteran GAF scores of 50 to 55 in 2010-2011, indicating moderate to severe impairment. The December 2011 examiner assigned the Veteran a GAF score of 55, indicating moderate impairment. The two latter scores are more consistent with the overall picture painted by the Veteran's symptomology, as his symptoms were consistently judged by mental health professionals to be moderate. Specifically, the Board notes that the examiner stated that the Veteran's distress was severe at times, and impairment due to PTSD symptoms was moderate overall. Viewed as a whole, and because the GAF score is only one of the factors which are considered, the Board finds that the symptoms exhibited by the Veteran more nearly approximate those contemplated by the 50 percent disability rating. Therefore, the 50 percent rating shall be assigned to the Veteran for the entire period on appeal. The Board is unable to distiniguish a time during the period of the appeal when the symptoms warranted any higher or lower rating. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The Board finds that the results of the VA examinations and the symptoms described in the VA examination reports, VAMC treatment notes, and lay statements do not indicate that the Veteran experiences all of the symptoms associated with a 50 percent disability rating for a psychiatric disability. However, the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather should serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is occupational and social impairment resulting in deficiencies in most areas is sufficient to warrant a 50 percent disability rating, even though all the specific symptoms listed for a 50 percent rating are not manifested. Consideration has been given to assigning a higher disability rating for the entire period on appeal. However, there is no indication from the evidence of record that the Veteran has experienced occupational and social impairment with deficiencies in most areas during the period under consideration. The Board notes that the Veteran did not show such symptoms as obsessional rituals which interfered with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting his ability to function independently, appropriately, and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or inability to establish and maintain effective relationships. At all the examinations, the Veteran's speech was unremarkable; he was well-oriented, well-groomed, and neatly dressed; his behavior was appropriate; and he was able to function independently, appropriately and effectively both socially and at his place of employment. He described having a generally good relationship with his wife and children, and stated that he had coping strategies, such as going to his car and attending therapy, for managing his symptoms. While the Veteran did report a fight at a sporting event, that was an isolated incident, and he did not experience periods of violence. While the Veteran stated that he sometimes had difficulty with his managers at work, he has been able to maintain the same job for 38 years. Therefore, a higher rating is not warranted. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration. 38 C.F.R. § 3.321(b) (1) (2013). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. 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 the 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. Thun v. Peake, 22 Vet. App. 111 (2008). The record shows that the manifestations of the Veteran's disability are contemplated by the schedular criteria. There is also no indication from the evidence of record that the Veteran has had frequent hospitalizations or received frequent emergency treatment for his PTSD. Additionally, the Veteran was able to work steadily at the post office for 38 years and his current symptoms of PTSD are not shown to have rendered him unemployable. In sum, there is no indication that the average industrial impairment from the disability would be to such a degree as to warrant the assignment of a higher disability rating than that granted herein. There are higher ratings available for the disability, but the evidence does not show that the Veteran's symptoms meet the criteria for the assignment of those ratings. The Board finds that referral of this case for extra-schedular consideration is not in order. Accoridngly, the Board finds that a 50 percent initial rating is warranted for PTSD. However, the Board finds that the preponderance of the evidence is against the assignment of any higher rating during the period on appeal. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection for Right Ear Hearing Loss 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, 1131 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303 (2013). In order to establish entitlement to service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease of injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For the purpose of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2013). The Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Veteran asserts that he has bilateral hearing loss disability as a result of exposure to hazardous noise while in active service. Specifically, the Veteran has reported that a grenade exploded right next to him, on his right side, while he was in combat in Vietnam. The Veteran also reported that he was exposed to the noise of weapons fire and heavy equipment while in active service. A review of the record shows that the Veteran had service in Vietnam as a light weapons infantryman. As the Veteran's report of sustaining acoustic trauma during service resulting in immediate hearing loss is consistent with the circumstances of his service, the Board concedes that the acoustic injury occurred as described by the Veteran and that the Veteran was exposed to acoustic trauma while in active service. In addition, the RO has granted service connection for tinnitus based on acoustic trauma during service. A review of the Veteran's service medical records shows that he was diagnosed with neuro-sensory hearing loss due to acoustic trauma in February 1969. The Veteran complained about having difficulty hearing from the right ear and of tinnitus in the right ear. After performing two hearing tests using the Rinne and Weber tests, the doctor diagnosed neuro-sensory hearing loss, without noting whether the diagnosis related to the right ear only or to both ears. The doctor noted that the hearing loss was "prob. temporary" and that the Veteran's tympanic membranes were intact bilaterally and moved well. The doctor also noted that the Veteran was able to return to duty and should be given an audiological examination at the time of his separation physical. It appears from the Veteran's service medical records that he was not provided an audiological examination at the time of his March 1969 separation examination. Therefore, the Veteran's hearing acuity at the time of his separation from active service cannot be determined. In addition, the Veteran's service medical records contain an undated Maico Audiogram, which appears to show raw data that appears to reveal positive findings. In addition, while there is no indication that the Veteran was afforded an audiogram at the time of his separation examination in March 1969, the Veteran has reported that he first experienced hearing loss in active service and has continued to experience hearing loss since his separation from active service, and he was diagnosed with hearing loss while in active service. The Veteran is competent to report when his symptoms of hearing loss began and that they have continued since his active service. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Moreover, the Board finds the Veteran credible in that assertion. At a September 2010 VA examination, the Veteran reported in-service hazardous noise exposure, including a grenade exploding near him, and reported no post-service occupational or recreational noise exposure. An audiogram was performed, but no consistent pure tone thresholds could be subjectively obtained for rating purposes, even with repeated instruction. The examiner did not explain why test results could not be obtained. The examiner noted that the speech recognition test scores were 92 for the right ear and 96 for the left ear. The examiner diagnosed non-organic bilateral hearing loss. The examiner was also asked to provide an opinion regarding the etiology of the Veteran's bilateral hearing loss disability. The examiner stated that she could not opine as to whether the Veteran's bilateral hearing loss disability was incurred while in combat in Vietnam without resorting to speculation. The examiner noted that the Veteran did not have an audiological examination performed following the acoustic trauma and there was no separation audiological examination. For the purpose of applying the laws administered by VA, impaired hearing will be considered a disability when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2013). The Veteran's speech recognition score for his right ear was 92 percent, which is below the 94 percent threshold. Therefore, the Veteran is deemed to have impaired hearing in the right ear for VA purposes. Therefore, medical evidence shows that the Veteran has a current right ear hearing loss disability. Both the Veteran's lay testimony and contemporaneous service medical records show that he experienced acoustic trauma while in service. In addition, he complained of hearing loss during service. In order to establish service connection, there still must be a nexus linking that in-service noise exposure to the current hearing loss disability. Such a nexus has not been shown here, as the VA audiologist who conducted September 2010 examination could not opine as to whether the Veteran's in-service noise exposure had contributed to his right ear hearing loss without resorting to speculation. However, the Board may not rely on the September 2010 VA examiner's opinion as a basis for denying the Veteran's claim. Indeed, that opinion is inherently speculative in nature and, therefore, is of limited probative value. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Moreover, the examining audiologist did not provide a rationale for the opinion, which further reduces its evidentiary weight. Sklar v. Brown, 5 Vet. App. 140 (1993). Further, audiologist did not take into account the Veteran's lay assertions of in-service acoustic trauma and ensuing hearing problems, which reportedly have persisted on a continuous basis since his active duty. That lay evidence is highly relevant to the Veteran's claim and must be considered. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examiner must consider lay evidence of in-service incurrence or continuity of symptomatology since service). In addition, the examiner's opinion is internally inconsistent. While the examiner stated that she was unable to obtain audiogram results, and said that the Veteran's speech discrimination was excellent bilaterally, she also diagnosed the Veteran with non-organic bilateral hearing loss. That diagnosis is not explained and not supported by the rationale contained in the opinion. Furthermore, the findings recorded at the examination were of a level of speech discrimination that is recognized by VA as indicative of hearing loss disability. The Board is free to assess medical evidence and is not obligated to accept a physician's opinion. Wilson v. Derwinski, 2 vet. App. 614 (1992). The Board declines to accept the VA examiner's opinions regarding the etiology of the Veteran's right ear hearing loss disability as the VA examiner did not sufficiently support the conclusion. The examiner did not address the Veteran's lay statements regarding the onset of his hearing loss. Additionally, the examiner did not address the Veteran's significant exposure to acoustic trauma during active service. Further, in light of the Veteran's minimal post-service noise exposure, the examiner also did not provide any other causal explanation for the Veteran's hearing loss. Therefore, as the VA opinion is inadequate, it cannot serve as the basis of a denial of entitlement to service connection. The Board notes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F .3d 1331 (Fed. Cir. 2006). The Veteran is competent to identify right ear hearing loss disability and his statements of such have been found credible. In sum, the Veteran currently has right ear hearing loss disability for VA purposes. VA has conceded the Veteran's acoustic trauma during active service. The Veteran has competently reported that he first experienced hearing loss while in active service and that he has continued to experience it since that time, and those statements have been found credible by the Board. While there is a medical opinion of record indicating that the examiner was unable to opine as to whether the Veteran's hearing loss disability was related to his active service noise exposure without resorting to speculation, that opinion does not consider all pertinent facts and does not provide a complete, thorough, and detailed rationale supporting the conclusions made. Accordingly, the Board finds that the evidence for and against the claims of entitlement to service connection for right ear hearing loss disability is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection for right ear hearing loss disability is warranted. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating of 50 percent, but not higher, for PTSD is agranted. Entitlement to service connection for right ear hearing loss disability is granted. REMAND The Board finds that additional development is required before the claim of entitlement to service connection for left ear hearing loss disability is decided. The Veteran asserts that he has bilateral hearing loss as a result of occupational noise exposure sustained while. The Board has conceded acoustic trauma during service, as the RO has granted service connection for tinnitus based on acoustic trauma during service. In addition, in this opinion, the Board has granted the Veteran service connection for a right ear hearing loss disability. The Veteran's service medical records show an in-service diagnosis of hearing loss in February 1969. In addition, while there is no indication that the Veteran was afforded an audiogram at the time of his separation examination in March 1969, the Veteran has reported that he first experienced hearing loss in active service and has continued to experience hearing loss since his separation from active service. The Veteran is competent to report when his symptoms of hearing loss began and that they have continued since his active service. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Moreover, the Board finds the Veteran credible in that assertion. In addition, the Veteran's service medical records contain an undated Maico Audiogram, which appears to show raw data that appears to reveal positive findings. At the September 2010 VA examination, the Veteran reported that he had bilateral hearing loss as a result of occupational noise exposure sustained while in active service, including a grenade exploding near him, and reported no post-service occupational or recreational noise exposure. The examiner performed an audiogram, but no consistent pure tone thresholds could be subjectively obtained for rating purposes, even with repeated instruction. The examiner did not explain why test results could not be obtained. The examiner noted that the speech recognition test scores were 92 for the right ear and 96 for the left ear. The examiner diagnosed non-organic bilateral hearing loss. The examiner was also asked to provide an opinion regarding the etiology of the Veteran's hearing loss disability. The examiner stated that she could not opine as to whether the Veteran's hearing loss disability was incurred while in combat in Vietnam without resorting to speculation. In this regard, the examiner noted that the Veteran did not have an audiological examination performed following the acoustic trauma and there was no separation audiological examination. Unfortunately, that opinion is inadequate. Examinations are inadequate where the examiner does not comment on the Veteran's report of relevant injury in service and, instead, relies on the absence of evidence in service medical records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007). In addition, the opinion is speculative, as no objective audiogram results could be obtained. It is also internally consistent, as the examiner diagnosed the Veteran with bilateral hearing loss, but did not provide a rationale for that diagnosis, and the examination report appears to contradict the final diagnosis. VA has granted service connection for right ear hearing loss disability based on the fact that the Veteran's speech recognition test score was 92 for the right ear, constituting hearing loss for VA purposes. The Veteran's hearing acuity in his left ear could not be assessed with an audiogram, as the examiner was not able to obtain audiogram readings. Once VA undertakes the effort to provide an examination, even if not statutorily obligated to do so, VA must provide an adequate one or notify the claimant when one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Veteran should be provided a VA examination to determine the nature and etiology of any left ear hearing loss disability. Current treatment records should be obtained before a decision is rendered with regard to the above issue. Accordingly, the case is REMANDED for the following action: 1. Obtain all pertinent VA medical records, not yet associated with the claims file. 2. Then, schedule the Veteran for a VA audiology examination. The examiner must review the claims file and should note that review in the report. The examiner should take into account the Veteran's medical, occupational, and recreational history since service, and his claim of continuing symptoms since service. A complete rationale for all opinions expressed should be provided. The examination must include testing of pure tone thresholds at 500, 1000, 2000, 3000, and 4000 Hertz and speech recognition scores using the Maryland CNC Test. All indicated studies should be conducted, and all findings reported in detail. The examiner should provide the following information: (a) The examiner should interpret the data on the undated in-service Maico Audiogram found in the Veteran's service medical records file and should state whether or not that audiogram indicates left ear hearing loss during service. (b) Taking the interpretation of the undated in-service Maico Audiogram data into consideration, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current left ear hearing loss is related to exposure to acoustic trauma during service. (c) The examiner should state whether it is at least as likely as not (50 percent or greater probability) that any current left ear hearing loss is due to or the result of the service-connected tinnitus or right ear hearing loss. (d) The examiner should state whether it is at least as likely as not (50 percent or greater probability) that any current left hearing loss is aggravated (permanently increased in severity beyond the natural progress of the disorder) by the service-connected tinnitus or right ear hearing loss. 3. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs