Citation Nr: 1602434 Decision Date: 01/21/16 Archive Date: 01/28/16 DOCKET NO. 12-17 278 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based on individual unemployability (TDIU) as due to service-connected disabilities. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Veteran and Spouse ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from October 1965 to September 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Detroit, Michigan Department of Veterans Affairs (VA) Regional Office (RO). A September 2011 rating decision awarded service connection for PTSD and assigned a 30 percent disability rating. The Veteran disagreed with the disability rating assigned and perfected an appeal on the claim for an increased initial disability rating for PTSD. A November 2013 rating decision denied service connection for hearing loss and tinnitus. The Veteran perfected an appeal on these issues. The Veteran testified at a hearing before the undersigned Veterans Law Judge of the Board via a video conference (video conference hearing) in October 2015. A transcript of that hearing has been associated with the claims file. The TDIU claim has been raised by the Veteran and record during the pendency of this appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that VA must address the issue of entitlement to a TDIU in increased-rating claims when the issue of unemployability either is raised expressly or by the record. See also Hurd v. West, 13 Vet. App. 449 (2000); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009); see also Mayhue v. Shinseki, 24 Vet. App. 273 (2011). As there is evidence of marginal employment in the record, the Board is assuming jurisdiction over this derivative TDIU claim, which dates back to the earliest time that the increased initial rating claim on appeal was originally filed. A review of the claims file includes a review of the paper file, Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. FINDINGS OF FACT 1. Resolving all doubt in favor of the Veteran, his bilateral hearing loss preexisted service and underwent an increase in severity during service. 2. Resolving all doubt in favor of the Veteran, his tinnitus was caused by in-service noise exposure. 3. Throughout the duration of the appeal, the probative evidence of record indicates the Veteran's PTSD is productive of occupational and social impairment with deficiencies in most areas, including work, family relations, judgment, thinking and mood. 4. Affording the Veteran the benefit of the doubt, the probative evidence of record indicates that, during the entire appeal period, the Veteran's service-connected PTSD precluded the Veteran from obtaining and maintaining employment that could be considered substantially gainful versus just marginal by comparison, when also considering his level of education, prior work experience and training, but not his advancing age or disabilities that are not service-connected. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for bilateral hearing loss are met. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306, 3.307, 3.309, 3.385 (2015). 2. The criteria for the establishment of service connection for tinnitus are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). 3. The criteria for an initial disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2015). 4. The criteria for a TDIU have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18 and 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2015). To the extent possible, VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2014), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The duty to notify was satisfied by way of August 2011 and March 2013 letters sent to the Veteran. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes STRs, VA medical records, VA examinations, Disability Benefits Questionnaires (DBQs) completed by a private audiologist and a private psychiatrist, and statements and testimony from the Veteran, his wife, and his representative. The Board notes that the August 2011 and April 2013 VA examination reports reflect that the examiner reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, the Board concludes that the medical examinations are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran testified at a Board hearing in October 2015. The hearing was adequate as the Veterans Law Judge explained the issue on appeal and, through questioning, attempted to identify possible sources of any evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. Rather, remanding this case to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). There is no indication there exists any additional evidence that has a bearing on this case that has not been obtained and that is obtainable. The Veteran has been accorded ample opportunity to present evidence and argument in support of this appeal. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2015). Analysis Service connection After a careful review of the record, and resolving all doubt in favor of the Veteran, the Board has determined, based upon the probative evidence of record, that service connection is warranted for hearing loss and tinnitus. 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 2014); 38 C.F.R. § 3.303(a) (2015). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing: (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 or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Caluza v. Brown, 7 Vet. App. 498 (1995). 1. Hearing Loss Service connection will also be presumed for certain chronic diseases, including hearing loss, if manifested to a compensable degree within one year after discharge from service. 38 U.S.C.A. § 1112; 38 C.F.R §§ 3.307, 3.309. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. § 1113. Every veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable (obvious or manifest) evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304(b) (2014); see also Wagner v. Principi, 370 F.3d 1089, 1090 (Fed. Cir 2004). In this case, the July 1965 service entrance examination demonstrated some evidence of hearing loss in both ears; therefore, the Veteran's hearing cannot be presumed to have been in sound condition upon his entrance into active service. It is the veteran who bears the burden of establishing aggravation under 38 U.S.C.A. § 1153. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed.Cir.1994). In other words, the Veteran must submit, or the record must contain, some evidence demonstrating that the preexisting disability increased in severity during service for the presumption of aggravation to attach. See Wagner, supra; Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Once the presumption of aggravation under section 1153 attaches, it may be rebutted only by clear and unmistakable evidence. See Cotant, supra; 38 C.F.R. § 3.306(b). The evidence of record demonstrates aggravation of the Veteran's hearing loss during service, considering both his account of in-service noise exposure and the service records which support this statement. The Veteran's DD form 214 reflects that he served in the Republic of Vietnam during the Vietnam War era and his military occupational specialty (MOS) was that of a cannoneer. Thus the record supports his claims of in-service noise exposure. 38 U.S.C.A. § 1154. The Board observes that, following the July 1965 entrance examination, there was no other audiological evidence of hearing loss during the Veteran's active service. Specifically, the September 1967 separation examination did not provide a whisper voice or audiology examination of the ears and, thus, there was no hearing evaluation at separation to compare with the entrance examination. Although the Veteran submitted a private physician's opinion in December 2014 finding that hearing loss was at least as likely as not caused by or the result of noise exposure during his active service, the examiner failed to note the service entrance examination demonstrated some hearing loss in both ears, thereby indicating preexisting hearing loss. However, this opinion does indicate that the private audiologist regarded the in-service noise exposure as severe enough to have an effect on the Veteran's hearing. Resolving all doubt in favor of the Veteran, the Board finds there is evidence of an increase in severity of his hearing loss in service and therefore the presumption of aggravation applies and hearing loss is presumed to have been aggravated by active service. See 38 U.S.C.A. § 1153; see also Wagner, supra. Despite the VA examiner's opinion in April 2013 that the Veteran's hearing loss was less likely than not related to military service and that his hearing loss preexisted service and was not aggravated by his active service, the examiner failed to discuss the fact that no hearing examination was provided to the Veteran at separation from service, therefore no audiology results at separation could be measured against the entrance examination. Moreover, the examiner's opinion failed to address whether the evidence was "clear and unmistakable" that hearing loss was not aggravated by the Veteran's active service. In this case, because there was no separation examination and considering the Veteran's in-service noise exposure, which is supported by his service records, it does not appear there was "clear and unmistakable" evidence that the Veteran's preexisting hearing loss was not aggravated by his active service. Therefore, the evidence of record does not rise to the level of clear and unmistakable evidence that hearing loss was not aggravated by service and the presumption of aggravation is not rebutted. Accordingly, service connection for hearing loss is warranted. 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2015). See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Tinnitus As noted above, the record supports his claims of in-service noise exposure. 38 U.S.C.A. § 1154. See 38 U.S.C.A. § 1154(a) (West 2014). The Veteran's STRs are absent of any complaints of ringing in the ears or treatment for tinnitus at any time throughout his active service. The medical evidence of record demonstrates the Veteran has a current diagnosis of tinnitus. Because of the inherently subjective nature of tinnitus, it is readily capable of even lay diagnosis and the Veteran, as a layperson is competent to testify as to his symptoms, specifically to experiencing tinnitus in service and since that time. See Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398 (1995); see also Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board finds the Veteran's statements and testimony regarding having tinnitus in service and since that time are credible. See Baldwin v. West, 13 Vet. App. 1 (1999); see also Dalton v. Nicholson, 21 Vet. App. 23 (2007). Although the April 2013 VA examiner found it was less likely than not that tinnitus was related to noise exposure encountered during active military service, the Board also finds the Veteran's statements of experiencing tinnitus since his active service competent and credible evidence. Additionally, a private audiologist provided an opinion in December 2014 in which he found that it was at least as likely as not that tinnitus was caused by or a result of noise exposure during active service. The Board observes that tinnitus was not noted in the service entrance examination, so unlike hearing loss, the Veteran is presumed to have been in sound condition with respect to tinnitus at the time of his entrance into active service. Therefore, the evidence of record, taken together, at the very least places the evidence in a state of relative equipoise as to whether tinnitus was caused by in-service noise exposure, and the Board must resolve this doubt in the Veteran's favor and grant the claim for service connection for tinnitus. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Initial Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2015). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. The Veteran's PTSD is assigned an initial 30 percent disability rating under 38 C.F.R. § 4.130, DC 9411, which is evaluated under the general rating formula for mental disorders. Under this general rating formula, a 30 percent rating is assigned where there is 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, and mild memory loss. 38 C.F.R. § 4.130, DC 9411 (2015). A 50 percent rating is warranted 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted 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. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). See also Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Accordingly, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. The medical evidence of record, including the VA medical records, VA examination reports, the July 2014 DBQ evaluation and July 2014 private psychiatric evaluation, collectively indicates that, throughout the duration of the appeal, the Veteran's PTSD was productive of symptoms, at worst, resulting in occupational and social impairment with deficiencies in most areas, including work, family relations, judgment, thinking and mood. VA medical records from January 2011 to July 2015 reflect that the Veteran's PTSD symptoms included depressed mood; anxiety; weekly panic attacks and near continuous panic; chronic sleep impairment; mild memory loss; impairment of short and long term memory; flattened affect; impaired judgment; disturbances in motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances; including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation; and impaired impulse control. The Veteran continued to seek group therapy for PTSD at the VA medical center. The July 2014 DBQ characterized the Veteran as having occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. A July 2014 private psychological evaluation was provided in addition to the July 2014 private DBQ, in which the Veteran's symptoms were found to cause severe social, personal and occupational impairment. PTSD symptoms in this evaluation included difficulty concentrating, generalized anxiety with three to four panic attacks per week, short and long term memory loss, flashbacks/intrusive thoughts, insomnia and other sleep disturbance, overwhelming feelings of sorrow and guilt, withdrawal and bouts of moderately severe depression. A GAF of 45 was provided. Lay testimony from the Veteran's wife at the October 2015 video conference hearing reflects that she has witnessed the Veteran's symptoms of violent anger outbursts and irritability, including toward their grandchildren, and experienced marital problems. Throughout the period of the appeal, his GAF scores have ranged from a low of 45 to a high of 65, thereby indicating severe or serious symptoms at worst; however, because the disability ratings are not assigned based solely upon GAF scores, the Board finds it reasonable to conclude that the acquired psychiatric condition symptomatology described in the record more nearly approximates the criteria for a 70 percent rating. Accordingly, the probative lay and medical evidence of record supports the assignment of a disability rating 70 percent for PTSD throughout the duration of the appeal. Although an increased 70 percent rating is warranted, the preponderance of the evidence is against a finding of entitlement to an evaluation exceeding 70 percent at any time throughout the duration of the appeal. Despite the occupational and social impairment demonstrated in the record, the evidence of record does not show findings or complaints demonstrating total occupational and social impairment due to symptoms such as: gross impairment in thought processes or communication; 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; or memory loss for names of close relatives, own occupation or own name, so as to in turn warrant assignment of an even higher 100 percent schedular rating. While the record reflects the Veteran's report of a history of suicidal ideation, avoidance, panic attacks, sleep disturbance, serious occupational and social impairment, impaired impulse control due to irritability and difficulty in adapting to stressful environments, these symptoms are contemplated by the 70 percent rating being assigned. Although, as noted in Mauerhan, the Veteran need not have all or even most of the particular symptoms in order to warrant a 100 percent evaluation, his psychiatric symptomatology does not demonstrate total social and occupational impairment. See Mauerhan, 16 Vet. App. 436. Moreover, despite some findings of suicidal ideation in the July 2014 DBQ, the Veteran has not shown to be a persistent danger of hurting himself or others and VA medical records from March 2011, April 2011 and August 2014 reflect that he has been characterized as a lower suicide risk. See Mauerhan, 16 Vet. App. 436. In addition, continual mental status evaluations throughout the duration of this appeal reflect that his thought processes were logical, goal oriented and linear with no looseness of associations and that his thought content included no unusual content, hallucinations, paranoia or delusions. Therefore, the probative evidence of record does not more nearly approximate the criteria for a 100 percent disability rating at any time since the filing of the claim for this disability. 38 C.F.R. §§ 4.3, 4.7. The Board has considered the lay statements of record regarding the severity of the Veteran's psychiatric disability and has relied on these reports in determining appropriate disability rating under the benefit-of-the-doubt doctrine. 38 C.F.R. §§ 4.3, 4.7 (2015). The Veteran and his wife are competent to report on factual matters of which they have firsthand knowledge and their statements regarding his symptoms are also credible, and thus, probative. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Baldwin v. West, 13 Vet. App. 1 (1999). Where the Veteran and his wife, have not discussed particular findings that are necessary for application to the rating criteria, the Board has accorded greater probative weight to objective medical findings of record which specifically address the rating criteria. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Accordingly, the Board concludes that the Veteran's PTSD warrants a disability rating of 70 percent, but no higher, throughout the duration of the appeal. 38 C.F.R. §§ 3.102, 4.3 (2015). See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Overall, there exists no basis under the schedular criteria for an initial disability rating in excess of 70 percent for this disability at any time throughout the duration of the appeal. 38 C.F.R. §§ 4.3, 4.7 (2015). Extraschedular Consideration There is no evidence of exceptional or unusual circumstances to warrant remand to refer this claim for extraschedular consideration. 38 C.F.R. § 3.321(b)(1) (2015). The threshold factor for extraschedular 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, there must be a comparison between the level of severity and the symptomatology of the Veteran's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is adequate, and no referral to the Director of the Compensation Service for consideration of an extraschedular rating is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described above, the manifestations of the Veteran's PTSD is contemplated by the schedular criteria. The criteria practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected PTSD such that he is adequately compensated for "considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See 38 C.F.R. § 4.1 (2015). Further, no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that remand for referral of this case for extraschedular consideration is not in order. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014) a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected symptoms experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected symptoms that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, as the Board has found a TDIU claim has been inferred with the claims on appeal and this issue is being granted, no further discussion of entitlement to TDIU is necessary. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b) ; 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1991); Alemany v. Brown, 9 Vet. App. 518 (1996). TDIU Total disability ratings are authorized for any disability or combination of disabilities provided the schedular rating is less than total, when the disabled person is unable to secure and maintain substantially gainful employment because of the severity of his service-connected disabilities. If there is only one such disability, it must be rated as at least 60 percent disabling. 38 C.F.R. § 4.16(a). The Veteran meets the preliminary schedular criteria for a TDIU under 38 C.F.R. § 4.16(a) due to his service-connected PTSD. In addition, when viewed as a whole, the evidence supports a finding that he is not capable of substantially gainful employment as a result of his service-connected PTSD. Specifically, the July 2014 private psychological evaluation concluded that, based on his education training past work experience and current level of symptoms, it was her professional opinion that the Veteran was not a viable rehabilitation candidate nor was he capable of sustaining substantial gainful work activity. She specifically found that he was unemployable. Thus, resolving all doubt in favor of the Veteran, the probative evidence of record demonstrates that he is unemployable or capable of no more than marginal employment due to his PTSD symptoms. Accordingly, the criteria for a TDIU due to service-connected PTSD are met. ORDER Service connection for bilateral hearing loss is granted. Service connection for tinnitus is granted. A disability rating of 70 percent, though no higher, for PTSD, is granted, subject to the regulations applicable to the payment of monetary benefits. Entitlement to a TDIU due to service-connected PTSD is granted, subject to the regulations applicable to the payment of monetary benefits. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs