Citation Nr: 1341335 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 11-20 496 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for bilateral pes planus. 3. Entitlement to an initial rating in excess of 30 percent prior to May 1, 2013, and a rating in excess of 50 percent since, for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD J. Turner, Associate Counsel INTRODUCTION The Veteran served on active duty from July 2002 to July 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri that in relevant part denied the above claims. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of entitlement to service connection for bilateral pes planus is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran has not been diagnosed with hearing loss, for VA rating purposes, in either ear. 2. Prior to May 1, 2013, the Veteran's PTSD was manifested by occupational and social impairment due to symptoms such as depression, impaired sleep, social isolation, lack of motivation, panic attacks; it was not manifested by symptoms severe enough to result in deficiencies in most areas of life due to symptoms as severe as near-continuous panic or depression, neglect of personal appearance and hygiene or an inability to establish and maintain effective relationships. 3. Since May 1, 2013, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas due to symptoms such as a lack of energy, impaired short-term memory, social isolation, impaired judgment, daily panic attacks, and disturbances in mood and motivation; it was not manifested by total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, an intermittent ability to perform activities of daily living, disorientation to time or place or significantly impaired memory. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103(a), 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2013). 2. The criteria for establishing entitlement to an initial disability evaluation of 50 percent for service-connected PTSD prior to May 1, 2013, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for establishing entitlement to a disability evaluation of 70 percent since May 1, 2013, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for entitlement to service connection for hearing loss, entitlement to an initial rating in excess of 30 percent prior to May 1, 2013 for PTSD, and a rating in excess of 50 percent since, for PTSD. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). A. Duty to Notify When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Compliance with the first element requires notice of the five service connection elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C.A. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). The initial rating appeal arises from a granted claim of service connection. Compliance with the first notice element requires notice of the five service connection elements in initial ratings cases: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dunlap v. Nicholson, 21 Vet. App. 112 (2006). Prior to initial adjudication of the Veteran's claims, a November 2009 letter fully satisfied the duty to notify provisions, including notice of the degree of disability. 38 U.S.C.A. § 5103(a); 38 C. F.R. § 3.159(b)(1). B. Duty to Assist The Board also concludes VA's duty to assist in obtaining records has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c); McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The Veteran was afforded a January 2010 medical examination to obtain an opinion as to whether his hearing loss was the result of his military service. This opinion was rendered by a medical professional following a thorough examination and interview of the Veteran and review of the claims file. The examiner obtained an accurate history and listened to the Veteran's assertions. The examiner laid a factual foundation and reasoned basis for the conclusions that were reached. Therefore, the Board finds that the examination is adequate. See Nieves-Rodriguez, 22 Vet. App. at 300. In addition, the RO provided the Veteran an appropriate VA examination in January 2010, February 2011, and May 2013, for evaluation of his PTSD. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA, mentioned above, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The examination report provides sufficient evidence to apply the ratings schedule and to determine that the schedular rating fully contemplates the Veteran's disability. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); see also VAOPGCPREC 11-95. The aforementioned VA examination reports are thorough and supported by VA outpatient treatment records. The examinations in this case are an adequate basis on which to adjudicate the claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). I. Service Connection The Veteran contends that he is entitled to service connection for bilateral hearing loss. However, the evidence of record demonstrates that the Veteran does not suffer from hearing loss for VA rating purposes. As such, service connection is not warranted. Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). To establish entitlement to service-connected compensation benefits, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred during service. Shedden v. Prinicipi, 381 F.3d 1163, 1167 (Fed. Cir 2004). The Veteran's service treatment records reflect that he did not suffer from bilateral hearing loss during active duty. According to a January 2010 VA examination, pure tone thresholds, in decibels (dB), were: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 15 10 LEFT 10 10 5 5 10 The Veteran's speech recognition score for the right ear was 100 percent, and 98 percent for the left ear. The above results demonstrate that the Veteran was not suffering from hearing loss, for VA rating purposes, two years after his separation from active duty in July 2008. For VA purposes, hearing impairment is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 dB or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 CFR § 3.385 (2013). The above evidence demonstrates that the Veteran is not entitled to service connection for bilateral hearing loss. There is no evidence of a hearing loss disability following separation from active duty and there is no evidence of a present hearing loss disability. There must be a current diagnosis of a disorder for service connection to be granted. Hickson v. West, 12 Vet. App. 247, 252 (1999). Without a medical diagnosis of hearing loss, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for bilateral hearing loss must be denied. III. Increased Rating The Veteran was granted service connection for PTSD in a July 2010 rating decision. A notice of disagreement was received from the Veteran in September 2010. In a May 2013 supplemental statement of the case, the 30 percent evaluation was increased to 50 percent, effective as of May 1, 2013. As such, the issue before the Board is entitlement to an initial disability evaluation in excess of 30 percent prior to May 1, 2013, and entitlement to an evaluation in excess of 50 percent since. For the reasons that follow, the Board concludes that an increased rating for both periods on appeal is warranted. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). Under the provisions for rating psychiatric disorders, a 30 percent disability rating requires evidence of the following: 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). The criteria for a 50 percent rating are: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: 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.) The criteria for a 100 percent rating are: 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. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 442-43. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Although the Veteran's symptomatology is the primary consideration, the veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (2013). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)). GAF scores ranging from 41 to 50 illustrate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning. In a January 2010 VA examination, the Veteran reported he was presently engaged to another woman, was expecting a child, and stated that he and his fiancée got along "good, I suppose," though they argued about leaving the house, which the Veteran did not wish to do often. He said he got along well with his parents and brother. However, he denied having any friends, saying he lost contact with old friends. He was employed as a mechanic and reported no problems on the job. The Veteran stated he used to enjoy 4-wheeling, but noted "I don't really do anything now. I don't feel like doing it and don't like being around too many people." He reported his mood was "okay" in general. He was oriented to person, time and place. The Veteran endorsed difficulty falling and staying asleep, getting two to three hours of sleep per night, and experiencing constant fatigue. He stated his sleep difficulties were attributable to military-related nightmares. The Veteran denied hallucinations, and homicidal or suicidal ideation. Additionally, the Veteran stated he has obsessive behavior, stating that he must make sure the alarm is set on the house. He also endorsed panic attacks, occurring once per month since 2008, and two to three times per week since 2009. He stated he avoided talking or thinking about traumatic events in service. He reported avoiding crowds and weapons. He stated he was hyperalert and easily startled. The Veteran was able to maintain minimum personal hygiene. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 50. In February 2010, the Veteran received treatment at a VA Medical Center (VAMC). The Veteran stated he felt more relaxed since his marriage was finalized. However, he reported having to leave the shopping mall after a couple of minutes because the crowds of people induced a panic attack. He stated his nightmares occurred five to six times per week. The examiner noted nothing remarkable about the Veteran's appearance, and that his thought processes were logical and coherent. Additionally, the Veteran denied violent ideation, thoughts, intent and plan toward self and others. In a February 2011 VA examination, the Veteran stated that he felt sad most of the time and that he derived no pleasure from things he used to enjoy. He stated that his relationship with his wife was going okay, and that he got along well with his two step-children, but that they were the same age as the children firing at him during the war, which causes him to avoid them, which in turn caused him dissatisfaction. He stated that in the last year, his lack of energy and desire to be active had worsened significantly. However, he was able to maintain employment and a good relationship with his wife. His social interaction, he stated, was limited to his co-workers and wife. He described his mood as "okay, I guess. It's mellow, really tired." He reported difficulty sleeping, getting two to four hours of sleep per night, which was caused by persistent thoughts and apprehension about nightmares. He denied hallucinations. He reported that he often checks that the lights in his house are off and that the doors are locked. He also feels the need to keep track of the whereabouts of people in his house at all times, a habit which has worsened since his stepchildren reached the age of the children who fired on his during his service. The Veteran reported daily panic attacks, but denied homicidal or suicidal ideations, or episodes of violence. He noted he had good impulse control, and had the ability to maintain minimum personal hygiene. He reported that his feelings of social isolation had worsened in the last year, and had feelings of irritability and angry outbursts. He also reported memory and concentration difficulties, and frequent, disturbing memories of his in-service trauma, and feelings of guilt. He endorsed persistent feelings of depression. The examiner assigned a GAF score of 45. At a May 1, 2013 VA examination the Veteran stated he remained married, but said the relationship was strained by daily arguing and emotional distance. His relationship with his stepchildren remained strained. He reported constant vigilance about where the children where and what they were doing, and experienced concern that they were doing something destructive. He stated that he attempted to coach the children's soccer team, but had to quit due to discomfort around children. The Veteran reported being socially withdrawn, having no friends with which he spent time with outside of work. He continued to lack interest in activities. He remained employed at the same job, and got along well with the small group of people he worked with, which he attributed to there being few of them and that they are also Veterans. He reported having some difficulty with efficiency at work due to his forgetting how to do repetitive tasks that he had done for years. He was startled by explosions that occur on the military base at which he works. The Veteran stated that he experienced intrusive thoughts related to his stressor five to six times per week, which triggered depression and anxiety. He said his nightmares were nightly and tended to wake him. The Veteran stated he suffered from severe symptoms of hypervigilance, being easily startled. He also endorsed concentration deficits, irritability and difficulty sleeping. He stated that with medication he received four hours of sleep per night. He stated that he avoids talking and thinking about stressors. He reported avoiding crowds, and visited stores at 3 in the morning to avoid others. He noted emotional numbing, loss of interest, and feeling cut off from others. His panic attacks continued to occur daily. He stated his mood was depressed. The examiner further noted that in the PTSD questionnaire, the Veteran endorsed either the maximum or near maximum possible across all measures, suggesting a likelihood of over endorsement. However, the examiner felt this was likely a cry for help as the examiner felt the Veteran was legitimately distressed. In his September 2011 notice of disagreement, the Veteran endorsed daily panic attacks, as well as use of medication to control anxiety, depression and insomnia related to his PTSD. In his July 2011 VA Form 9, the Veteran stated that he attempted to coach his children's soccer team, but was unable to "because that is all [he] focus[ed] on and talk[ed] about was soccer." He stated he avoided crowds, mood swings, and lost relationships with friends and some family members. He reported difficulty adapting to stressful situations. He stated he had to drive a separate car to holiday and family gatherings in case there were "too many people," in which case he would get anxious and have to leave. He noted loss of sleep from nightmares about combat. He also stated that he had trouble focusing at work and sometimes wanted to hurt the people he worked with when provoked. He also stated he had short term memory problems. The above evidence demonstrates that the Veteran is entitled to an initial disability evaluation of 50 percent for his service-connected PTSD. As already noted, a 50 percent rating is warranted when a psychiatric disability results in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. According to the January 2010 and February 2011 VA examinations, the Veteran's PTSD was of such severity that it resulted in avoidance of social interaction, lack of any friends, difficulty sleeping, lack of interest in activities he once enjoyed, and two to three panic attacks per week. Since the Veteran's symptomatology was deemed to be of such severity as to result in occupational and social impairment with deficiencies in most areas, an initial disability evaluation of 50 percent is warranted. Likewise, the evidence of record demonstrates that the Veteran is entitled to an evaluation of 70 percent as of May 1, 2013, the date of the most recent VA examination. Again, a 70 percent rating contemplates 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); inability to establish and maintain effective relationships. According to the May 2013 VA examiner, the Veteran's PTSD was of such severity as to result in reduced reliability and productivity, due to symptomatology such as social isolation, impaired memory, impaired judgment, daily panic attacks, and disturbances in mood and motivation. The examiner also assigned a GAF score of 45. In total, the Board finds the Veteran is entitled to a higher disability evaluation of 70 percent is warranted as of May 1, 2013. The preponderance of the evidence of record demonstrates that the Veteran's PTSD has not resulted in total occupational and social impairment at any time. The Veteran has maintained a relationship with his wife and his children, and the Veteran is employed. The Veteran was alert and oriented during his May 2013 examination, with logical and goal directed thoughts, and speech within normal limits. The May 2013 VA examiner specifically concluded that the Veteran's PTSD did not result in total occupational and social impairment. A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. Since the preponderance of the evidence of record reflects that the Veteran's PTSD has not resulted in total occupational and social impairment at any time, a 100 percent evaluation is not warranted. Entitlement to a total disability rating based on individual unemployability (TDIU) is an alternative theory of all claims for a higher disability rating. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). TDIU may be raised explicitly by a claimant or inferred from the record. An inferred claim for a TDIU is raised as part of an increased rating claim only when certain requirements are met. Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009). TDIU is raised by inference when: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). In the present appeal, the Veteran is employed. Thus, the Board concludes that the Roberson requirements are not met and that consideration of TDIU is not warranted. In conclusion, when resolving all reasonable doubt in favor of the Veteran, the Board finds that an initial disability evaluation of 50 percent is warranted for the Veteran's PTSD, and, that a disability evaluation of 70 percent is warranted as of May 1, 2013. As such, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are applicable to this aspect of the Veteran's appeal and it is granted. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2010); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service- connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are not inadequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected PTSD, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. As such, referral for extraschedular consideration is not in order here. ORDER Entitlement to service connection for bilateral hearing loss is denied. A disability evaluation of 50 percent for PTSD, as of November 16, 2009, is granted, subject to the law and regulations governing the payment of monetary benefits. A disability evaluation of 70 percent for PTSD, as of May 1, 2013, is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Board must remand the claim for bilateral pes planus for a VA medical examination. The duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Veteran was never afforded a VA examination and opinion that addresses the extent of the Veteran's claimed bilateral pes planus and whether that disability is directly service-connected. In his September 2010 notice of disagreement, the Veteran stated that prior to joining the military he had "very high arches," but after service had pes planus. However, there is not presently enough information of record to resolve the issue. For the foregoing reasons, the Board finds that a VA examination should be issued concerning the Veteran's claim for bilateral pes planus. The examiner should offer an opinion as to whether there is a current bilateral pes planus disability, and if so, whether it is related to service. All lay and medical evidence should be considered, to include any assertions of continuity of symptomatology that may be made by the Veteran. In this regard, the Board notes that the Veteran is competent to report observable symptomatology, and the lack of contemporaneous medical records does not, in and of itself, render such lay evidence not credible. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006). However, this may be weighed against other lay and medical evidence of record. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all available VA treatment records. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. The AMC should schedule a VA examination to address the etiology of any bilateral pes planus disorder. All pertinent evidence, including information in Virtual VA and VBMS, should be made available to the examiner for review, and such review should be noted in the opinion report. The examiner should determine the following: a. The diagnosis of any bilateral pes planus disability which may be present. b. Whether any such bilateral pes planus is at least as likely as not (at least a 50-50 probability) incurred as a result of the Veteran's service. c. A complete rationale should be provided for all opinions given. The opinion should take into consideration and address all pertinent incidents of service. 3. Then, the AMC should readjudicate the claim on the merits. If the benefit sought is not granted, the Veteran and his representative should be furnished a SSOC and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs