Citation Nr: 1525528 Decision Date: 06/15/15 Archive Date: 06/26/15 DOCKET NOS. 11-11 836 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for bladder cancer, status post-transurethral resection of bladder tumor. 2. Entitlement to service connection for the cause of the Veteran's death. 3. Entitlement to an initial disability rating in excess of 50 percent prior to August 3, 2010, for a psychiatric disorder, including schizophrenia. 4. Entitlement to disability and indemnity compensation under 38 U.S.C.A. § 1318 (West 2014). 5. Entitlement to special monthly compensation (SMC) based on aid and attendance or housebound status. ATTORNEY FOR THE BOARD M. Caylor, Associate Counsel INTRODUCTION The Veteran had active military service from June 1954 to June 1956. He died in September 2013. The Appellant is his surviving spouse. This case comes before the Board of Veterans' Appeals (Board) from October 2010 and March 2011 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico and an August 2014 Decision Review Officer (DRO) decision from the RO in Philadelphia, Pennsylvania. The Board previously remanded the issues on appeal in July 2013. After the Veteran's death, the Appellant filed a claim for service connection for the cause of the Veteran's death. In August 2014, the Appellant was substituted for the Veteran in the appeals that were pending before the Board at the time of his death. In March 2011, the Veteran requested a videoconference hearing before a member of the Board; however, as he withdrew his request in an August 2014 statement, it is deemed withdrawn. See March 2011 Appeal Hearing Option (selecting DRO hearing); April 2013 Report of Contact (cancelling hearing); 38 C.F.R. § 20.704(d) (2014). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran's bladder cancer, status post-transurethral resection of bladder tumor, was not incurred in or aggravated by service; is not presumptively related to in-service herbicide exposure; did not manifest to a compensable level within a presumptive period; was not etiologically related to an in-service injury, event, or disease; and was not proximately due to or chronically aggravated by service-connected disability. 2. The Veteran died in 2013 from due to the primary causes of sepsis and bladder cancer; he was service connected for a psychiatric disorder, including schizophrenia, and right shoulder dislocation and acromioclavicular separation. 3. The Veteran's service-connected psychiatric disorder, including schizophrenia, and right shoulder dislocation and acromioclavicular separation did not contribute substantially or materially to his death, combine to cause death, or aid or lend assistance to the production of death. 4. Prior to August 3, 2010, the Veteran's psychiatric disorder, including schizophrenia, results in total occupational and social impairment despite undergoing psychotherapy, taking medication, and hospitalization, due to symptoms including at times incoherent or illogical thought processes and preoccupied thought content; persistent audio and visual hallucinations and delusions of persecution; persistent danger of hurting self or others due to poor impulse control, irritability, and verbal and physical aggression; intermittent inability to perform activities of daily living that involve crowds; depressed and anxious mood; isolation and social withdrawal; crying spells; constricted affect; lack of motivation and interest in activities; nightmares; poor to fair insight and judgment; and mild to moderate memory and concentration difficulty. 5. At the time of the Veteran's death, he had been rated totally disabled for 10 continuous years immediately preceding his death. 6. The Veteran required the aid and assistance of another person due to his service-connected psychiatric and right shoulder disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for bladder cancer, status post-transurethral resection of bladder tumor, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2014). 2. The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1310 (West 2014); 38 C.F.R. §§ 3.5, 3.312 (2014). 3. The criteria for an initial disability rating of 100 percent for a psychiatric disorder, including schizophrenia prior to August 3, 2010, have been met. 8 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2014). 4. The criteria for entitlement to DIC benefits under 38 U.S.C. § 1318 have been met. 38 C.F.R. § 1318 (West 2014); 38 C.F.R. § 3.22 (2014). 5. The criteria for an award of SMC based on the need for regular aid and attendance of another person have been met. 38 U.S.C.A. §§ 1114 (West 2014); 38 C.F.R. §§ 3.350, 3.352(a) (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties VA satisfied its duty to notify the appellant pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2014); Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). VA provided the required notice in a series of letters mailed to the Veteran and the Appellant. The Appellant has not asserted that any prejudice resulted from the receipt of notice after an initial rating decision, and the record reveals that the Veteran and the Appellant submitted relevant necessary evidence. VA also satisfied its duty to assist the Appellant in the development of her claims. VA satisfied its duty to seek relevant records. The RO associated the Veteran's service treatment records (STRs), private treatment records, VA treatment records, and death certificate with the claims file. The Appellant has not identified any other evidence not already of record; therefore, VA has made every reasonable effort to obtain all relevant records. VA satisfied its duty to obtain a medical opinion when required. VA satisfied its duty obtain a medical examination or opinion when required. The Veteran underwent several VA examinations regarding his claims. The examinations and opinions are adequate, as the examiners considered the relevant history of the Veteran's symptoms, provided sufficiently detailed descriptions of any disability, and included clear conclusions with supporting data. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). The Veteran was not provided a VA examination regarding his bladder cancer, however, because the record does not appear to contain competent evidence indicating that any bladder cancer may have been associated with his service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). STRs are silent for any complaints of bladder cancer and the Veteran did not appear to assert that he ever sought treatment for bladder cancer in service or during the five decades after his separation from service. While the Veteran believed and the Appellant believes the Veteran's bladder cancer was caused by an in-service injury, event, or disease, they are not competent to provide an indication that it may be associated with his service. The issues are medically complex and require specialized knowledge and experience. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). VA's duty to provide an examination or opinion under 38 U.S.C.A. § 5103A(d) is limited to claims for "disability compensation" and does not apply to DIC or cause-of-death claims. Wood v. Peake, 520 F.3d 1345, 1349 (Fed. Cir. 2008); DeLaRosa v. Peake, 515 F.3d 1319, 1321-22 (Fed. Cir. 2008). VA must, however, still "make reasonable efforts" to assist claimants in obtaining evidence necessary to substantiate their claims, and in a cause-of-death case those efforts may include obtaining a VA medical opinion. 38 U.S.C.A § 5103A(a)(1); Wood, 520 F.3d at 1348; DeLaRosa, 515 F.3d at 1322. However, as the Veteran's service-connected disabilities are not listed on his death certificate and no evidence appears to indicate that they were the primary or contributory causes of the Veteran's death, no medical opinion was required. As the Veteran was granted entitlement to a 100 percent rating prior to August 3, 2010, for a psychiatric disorder and entitlement to SMC and the Appellant was granted DIC benefits under 38 U.S.C.A. § 1318, the Veteran and the Appellant will not be prejudiced, and a discussion of the duties to notify and assist is unnecessary. As VA satisfied its duties to notify and assist the Appellant, no further action is needed to comply with 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and the Appellant will not be prejudiced by the adjudication of her claims. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Merits of the Claim A. Bladder cancer. The Appellant contends that the Veteran's bladder cancer is related to an in-service injury, disease, or event. See August 2011 Statement. If a veteran had at least 90 days of active service, a chronic disease may be presumed service-connected if it manifested to a compensable degree within a presumptive period following separation from active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309. A disease is considered chronic if there was a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time; isolated findings or a diagnosis including the word "chronic" do not establish chronicity. 38 C.F.R. §§ 3.303(b), 3.307. If a chronic disease existed in service or within a presumptive period after separation from active service, subsequent manifestations of that chronic disease, however remote, are service connected unless clearly attributable to intervening causes. 38 C.F.R. § 3.303(b), 3.307(d). If a chronic disease is diagnosed after separation from service and not within any applicable presumptive period, service connection may still be granted on a direct basis if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d). If a Veteran was exposed to an "herbicide agent," such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases will be service connected even if there is no in-service record of the disease in service. 38 C.F.R. §§ 3.307(a)(6), (d), 3.309(e) (2014). For disabilities other than those listed under § 3.309(e), service connection may still be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Stefl, 21 Vet. App. at 123 (noting that the "availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange"). To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted on a secondary basis where disability is proximately due to or the result of an already service-connected disability, or where a service-connected disability aggravates, or causes an increase in, a non-service-connected disability. 38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Appellant is not entitled to presumptive service connection for bladder cancer. Malignant tumors are listed as chronic diseases under 38 C.F.R. § 3.309(a), but the record does not appear to contain any evidence, and the Veteran did not appear to assert, that any tumors or bladder cancer manifested to a compensable degree within one year after the Veteran's separation from service in 1956 or that he had continuity of symptomatology related to his malignant tumors since service. There are no indications of bladder cancer in the Veteran's STRs, physical examinations from within the presumptive period were negative for any indications of bladder cancer, and VA treatment records reveal that he was not diagnosed until 2010. See March, April and May 2010 VA Treatment Records; October 1956 and August 1957 VA Examinations; May 1956 Separation Medical Examination and History (negative for any genitourinary or cancer findings). Further, bladder cancer is not presumptively related to herbicide exposure under 38 C.F.R. § 3.309(e) and the Veteran is not entitled to direct service connection based on herbicide exposure because the record fails to establish, and the Veteran did not appear to assert, that he ever had service in the Republic of Vietnam or was otherwise exposed to herbicides. The Appellant is not entitled to direct service connection for bladder cancer because competent, credible, and probative evidence fails to establish that it began during service or is otherwise etiologically related to any in-service injury, disease, or event. As noted above, the Veteran was diagnosed with bladder cancer over five decades after his separation from service, decades of private and VA treatment records do not demonstrate, and the Veteran did not appear to assert, that he had continuous symptoms since service that were related to the bladder or any bladder cancer, and no medical evidence indicates that it is otherwise related to his active service from 1954 to 1956. The evidence also does not appear to demonstrate, and the Veteran did not appear to assert, that his bladder cancer was proximately due to or chronically aggravated by his service-connected psychiatric and right shoulder disabilities. While the Appellant believes the Veteran's bladder cancer is due to his active service from 1954 to 1956, she is not competent to provide a medical nexus opinion in this case. The issue is medically complex, involving multiple systems of the body, and requires specialized knowledge and experience. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the preponderance of the evidence weighs against granting service connection for bladder cancer, status post-transurethral resection of bladder tumor. B. Cause of death. The Appellant contends that the Veteran's service-connected disabilities contributed substantially to the cause of his death. See April 2014 Notice of Disagreement. When a veteran dies of a service-connected disability, the veteran's surviving spouse is eligible to obtain DIC benefits for the cause of the veteran's death. 38 U.S.C.A. § 1310; 38 C.F.R. §§ 3.5(a), 3.312. To establish entitlement to DIC benefits for the cause of death, evidence must show that a service-connected disability was the principal or a contributory cause of the veteran's death. 38 U.S.C.A. § 1310; Hupp, 21 Vet. App. at 352. A service-connected disability is the principal or primary cause of death when it, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A service-connected disability is a contributory cause of death if it is not related to the principal cause and it contributed substantially or materially; combined to cause death; or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). The disability must have a causal connection to the veteran's death; it is not sufficient to show that it casually shared in producing death. Id. If the principal or contributory causes of a veteran's death are not yet service connected, a claimant seeking DIC benefits must first establish entitlement to service connection for those disabilities. Hupp, 21 Vet. App. at 352. The Veteran's death certificate states that the primary cause of the Veteran's death was sepsis and underlying bladder cancer. As discussed above, the Appellant is not entitled to service connection for bladder cancer; however, at the time of his death in September 2013, the Veteran was service connected for a psychiatric disorder, including schizophrenia, and right shoulder dislocation and acromioclavicular separation. As the record does not appear to contain any evidence that the Veteran's psychiatric and right shoulder disabilities contributed to or combined to cause the Veteran's death, the Appellant is not entitled to service connection for the cause of the Veteran's death. The Appellant believes that the Veteran's psychiatric and right shoulder disabilities were the primary or contributory cause of the Veteran's death; however, she is not competent to provide a medical opinion in this case. The issue is medically complex, involving multiple systems of the body, and requires specialized knowledge and experience. Jandreau, 492 F.3d at 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the preponderance of the evidence weighs against granting entitlement to DIC benefits for the cause of the Veteran's death. See 38 U.S.C.A. § 1310; 38 C.F.R. §§ 3.5(a), 3.312. C. Psychiatric disorder prior to August 3, 2010. The Appellant contends that the Veteran's psychiatric disorder, including schizophrenia, should be rated higher than 50 percent prior to August 3, 2010. See March 2011 and August 2006 Notices of Disagreement. Disability evaluations are governed by VA's Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2014). The percentage ratings in the Rating Schedule represent the "average impairment in earning capacity" resulting from service-connected disabilities, and residuals thereof, in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2014). Evaluating the same disability or manifestation under different diagnoses and using manifestations not resulting from service-connected disease or injury must be avoided. 38 C.F.R. § 4.14. If, however, multiple diagnostic codes each require "distinct and separate" symptomatology that does not duplicate or overlap with symptomatology required in the other diagnostic codes, a veteran may be assessed multiple ratings. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran's psychiatric disorder, including schizophrenia, is evaluated under the General Rating Formula for Mental Illnesses. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2014). The Board acknowledges that 38 C.F.R. sections 3.384, 4.125, 4.126, 4.127, and 4.130 were updated, immediately effective August 4, 2014. 79 Fed. Reg. 45,093, 45, 096 (Aug. 4, 2014). Generally, "where [a] law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to [the] appellant should . . . apply unless Congress provided otherwise or permitted the [Secretary] to do otherwise and the Secretary did so." Karnas v. Derwinski, 1 Vet.App. 308, 313 (1991). In this case, the Secretary directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to or pending before the Board, the CAVC, or the United States Court of Appeals for the Federal Circuit. 79 Fed. Reg. 45,093, 45,094. As the Veteran's claim was pending at the Board at the time of the regulation change, only the version of 38 C.F.R. § 4.130 effective prior to August 4, 2014, applies. Regardless, the Veteran will not be prejudiced, as the rating criteria in both the prior and current versions of 38 C.F.R. § 4.130 remain the same. See 79 Fed. Reg. 45,093, 45,094 ("This update to incorporate the current DSM will not affect evaluations assigned to mental disorders as it does not change the disability evaluation criteria . . . ."). Under the general rating formula for mental disorders, the following ratings apply. 38 C.F.R. § 4.130, Diagnostic Codes 9201-9440 (2014). A 50 percent rating applies if the veteran has occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating applies if the veteran has 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. Id. Finally, a 100 percent rating applies if the veteran has 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. Id. Under 38 C.F.R. § 4.126(a), an evaluation of a mental disorder must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The assigned rating should be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). While the evaluation should consider the extent of social impairment, a rating should not be assigned based solely on social impairment. 38 C.F.R. § 4.126(b). Further, the list of symptoms within the criteria for each rating is not exhaustive, so the impact of other symptoms particular to a veteran or a disorder on occupational and social functioning should also be considered. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran was diagnosed with more than one psychiatric disorder-schizophrenia and depressive disorder; however, separate ratings are not necessary. The June 2012 VA examiner opined that it was not possible to differentiate between the level of occupational and social impairment attributable to each diagnosis without resorting to speculation because some of the symptoms may overlap. Therefore, the Veteran's separately diagnosed disorders have a single manifestation and assigning separate disability ratings for each diagnosis would violate 38 C.F.R. § 4.14. See Amberman, 570 F.3d at 1381. Instead, applying 38 C.F.R. § 3.102 and VA's statements in 61 Fed. Reg. 52,698, one disability rating will be assigned based on all of the Veteran's manifested mental health symptoms. Based on the above laws and regulations, the Veteran's psychiatric disorder, including schizophrenia, was 100 percent disabling prior to August 3, 2010. Despite undergoing psychotherapy, taking prescribed medication, and being hospitalized, the Veteran had symptoms of at times incoherent or illogical thought processes and preoccupied thought content; persistent audio and visual hallucinations and delusions of persecution; persistent danger of hurting self or others due to poor impulse control, irritability, and verbal and physical aggression; intermittent inability to perform activities of daily living that involve crowds; depressed and anxious mood; isolation and social withdrawal; crying spells; constricted affect; lack of motivation and interest in activities; nightmares; poor to fair insight and judgment; and mild to moderate memory and concentration difficulty due to interaction of emotional with cognitive state. See June 2004 VA Neuropsychiatric Treatment Records (indicating that emotional state may interact with cognitive state to impact attention and concentration). Further, the October 2007 VA psychiatric examiner found the Veteran was "seriously compromised" during periods of exacerbation, which treatment records reflect occurred with some regularity due to the Veteran's family situation, stress regarding medical procedures, and inconsistent use of medication. Consideration of staged or extraschedular ratings is unnecessary, as the Veteran has been awarded the highest possible rating for his psychiatric disorder during the relevant period. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505, 511-512 (2007); 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). While the Veteran did submit statements saying he was unable to work due to service-connected disability, he withdrew his appeal for entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) during the relevant period, prior to August 3, 2010. See March 2011 Statement. Consequently, entitlement to a 100 percent rating prior to August 3, 2010, for a psychiatric disorder, including schizophrenia, is granted. D. DIC benefits under 38 U.S.C.A. § 1318. Under 38 U.S.C.A. § 1318(a), a surviving spouse may be paid DIC benefits as if the Veteran's death were service-connected if the veteran's death was not the result of willful misconduct; the veteran was receiving, or was entitled to receive, compensation for a service-connected disability that was rated by VA as totally disabling for a continuous period of at least 10 years immediately preceding death; was rated totally disabling continuously since the veteran's release from active duty and for a period of not less than 5 years immediately preceding death; or was rated as totally disabling for a continuous period of not less than one year immediately preceding death if the veteran was a former prisoner of war who died after September 30, 1999. The total rating may be based on application of the criteria in the rating schedule or on individual unemployability. 38 C.F.R. § 3.22(c); Nat'l Org. of Veterans' Advocates, Inc. v. Sec'y of Veterans of Veterans Affairs, 314 F.3d 1373 (Fed. Cir. 2003); see also 38 U.S.C.A. §§ 5314, 1174(h)(2), 5308-09; 38 C.F.R. § 3.22(b). "Hypothetical entitlement" is not a viable basis for establishing entitlement to DIC benefits under 38 U.S.C.A. § 1318 for claims filed after January 21, 2000. See Rodriguez v. Nicholson, 19 Vet. App. 275 (2005). As this decision grants an initial 100 percent disability rating for the Veteran's psychiatric disorders from his original claim to August 3, 2010, the Veteran was rated totally disabled for a continuous period of at least 10 years immediately preceding his death. Consequently, entitlement to DIC benefits under 38 U.S.C. § 1318 is warranted. E. SMC. The Appellant contends the Veteran should be granted SMC based on the need for aid and attendance of another person or being housebound. See April 2010 Claim; August 2011 Notice of Disagreement. SMC is payable to a person who is permanently bedridden or so helpless as a result of service-connected disability that he is in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l) (West 2014); 38 C.F.R. § 3.350(b) (2014). A prerequisite for granting SMC by reason of the need for regular aid and attendance of another person is a single service-connected disability rated as total. The Veteran's psychiatric disorder was assigned a rating of 100 percent at the time of his death in September 2013. His right shoulder disability was rated at 20 percent at the time of his death. His combined disability rating, rounding up to the closest number divisible by 10, was 100 percent. 38 C.F.R. § 4.25 (2014). SMC by reason of the need for regular aid and attendance of another person is payable if a Veteran, as the result of service-connected disability, either: (1) has suffered the anatomical loss or loss of use of both feet, (2) has suffered the anatomical loss or loss of use of one hand and one foot, (3) is blind in both eyes, (4) is permanently bedridden, or (5) is with such significant disabilities or so helpless as to be in need of regular aid and attendance. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). Determinations should be on the basis of a Veteran being permanently bedridden rather than needing regular aid and attendance to avoid reduction during hospitalization where aid and attendance is provided in kind. 38 C.F.R. § 3.350(b)(4). Bedridden means that the Veteran is actually required to remain in bed. 38 C.F.R. § 3.352(a). Voluntarily taking to bed or being prescribed bed rest for the greater or lesser part of the day to promote convalescence or cure is insufficient. Id. Several factors should be considered, including: (1) inability to dress or undress or to keep self ordinarily clean and presentable, (2) frequent need for adjustment of special prosthetic or orthopedic appliances that cannot be done without aid due to the particular disability (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.), (3) inability to feed self through loss of upper extremity coordination or extreme weakness, (4) inability of to attend to the wants of nature, (5) incapacity, physical or mental, requiring care or assistance on a regular basis to protect from hazards or dangers incident to his daily environment, and (6) being bedridden. Id. At least one of the above disabling factors be met to receive SMC based on required aid and attendance. Turco v. Brown, 9 Vet. App. 222 (1996); 38 C.F.R. § 3.352(a). The particular personal functions that the Veteran is unable to perform should be considered in connection with his condition as a whole. 38 C.F.R. § 3.352(a). It is only necessary that evidence establish the Veteran is so helpless as to need regular aid and attendance, not that there is a constant need. Id. The performance of the necessary aid and attendance service by a relative or other member of the Veteran's household will not prevent a favorable determination. 38 C.F.R. § 3.352(c). SMC by reason of being housebound is payable if a Veteran has a service-connected disability rated as total and either: (1) has an additional service-connected disability or disabilities independently ratable at 60 percent or more or (2) is permanently housebound by reason of his service-connected disability or disabilities. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran requires the aid and assistance of another person due to his service-connected psychiatric and right shoulder disabilities. Regarding his psychiatric disability, it resulted in concentration and memory difficulties that rendered the Veteran not competent to handle his VA benefits. His wife and son oversaw his finances, he had a food service deliver him meals, and his wife did all of the shopping because he was unable to be near crowds of people. Further, he needed to have someone else manage his medication to ensure consistent compliance and to protect against the hazard of impulsive overuse of prescription drugs during periods of depression. His right shoulder disability precluded driving and necessitated assistance in dressing and undressing, bathing, and household chores. See June 2012 and September 2010 VA Aid and Attendance Examinations; June 2012 and August 2010 VA Psychiatric Examinations; June 2012 VA Psychiatric Examination Addendum; July 2010 VA Joints Examination. Accordingly, the Board finds that the preponderance of the evidence supports the claim and entitlement to SMC based on the need for the regular aid and attendance of another person is warranted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As SMC by reason of the need for regular aid and attendance of another person is a greater monthly benefit than SMC by reason of being housebound and SMC based on the need for regular aid and attendance has been granted, a discussion of SMC based on being housebound is unnecessary. 38 U.S.C.A. §§ 1114(l), (s) (2014). ORDER Service connection for bladder cancer, status post-transurethral resection of bladder tumor, is denied. Service connection for the cause of the Veteran's death is denied. Entitlement to an initial disability rating of 100 percent for a psychiatric disorder, including schizophrenia prior to August 3, 2010, is granted. Entitlement to DIC benefits under 38 U.S.C. § 1318 is granted. SMC based on the need for regular aid and attendance of another person is granted. ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs