Citation Nr: 1616496 Decision Date: 04/26/16 Archive Date: 05/04/16 DOCKET NO. 14-10 944A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disability, including bipolar disorder, and, if so, whether service connection is warranted. 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a left knee disorder, and, if so, whether service connection is warranted. 3. Entitlement to service connection for a left hip disability. 4. Entitlement to service connection for a left ankle disability. 5. Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities. 6. Entitlement to a rating an increased evaluation for residuals of right ankle sprain, currently evaluated as 10 percent disabling. 7. Entitlement to an increased evaluation for right knee iliotibial band syndrome, currently evaluated as 10 percent disabling. 8. Entitlement to an increased evaluation for right hip iliotibial band syndrome, currently evaluated as 30 percent disabling. 9. Entitlement to an increased evaluation for lumbar strain, currently evaluated as 20 percent disabling. 10. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Mark R. Lippman, Attorney WITNESSES AT HEARING ON APPEAL The Veteran, his Spouse, and his Parents ATTORNEY FOR THE BOARD L. McCabe, Associate Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran served on active duty from August 1995 to December 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2013 and January 2014 rating decisions by the Montgomery, Alabama, Regional Office (RO) of the Department of Veterans Affairs (VA). A brief description of the procedural history is necessary to clarify the issues on appeal and the actions taken herein. In this regard, as pertinent to the present appeal, an August 1998 rating decision originally granted service connection for right hip iliotibial band syndrome (assigning a 30 percent rating effective January 1, 1998), lumbar strain (assigning a 10 percent rating effective January 1, 1998), and residuals of right ankle sprain (assigning a noncompensable (0 percent) rating effective January 1, 1998). A January 2002 rating decision denied the Veteran's June 2001 claim for service connection for a left knee disability. See June 2001 Statement in Support of Claim (VA Form 21-4138) (asserting entitlement to service connection for a disability affecting his left knee); January 2002 Rating Decision. In a November 2006 rating decision, the RO denied the Veteran's December 2005 claim for service connection for a psychiatric disability, and also denied his January 2006 claim for a rating in excess of 30 percent for his right hip iliotibial band syndrome. See December 2005 Veteran's Application for Compensation and/or Pension (VA Form 21-526) (asserting entitlement to service connection for depression); January 2006 Statement in Support of Claim (VA Form 21-4138) (requesting an increased rating for his service-connected right lower extremity disability); November 2006 Rating Decision. In January 2007, the Veteran disagreed with the RO's November 2006 determination. See January 2007 Notice of Disagreement. See also 38 C.F.R. §§ 20.200, 20.201, 20.302 (2015) (setting forth requirements and timeframe for initiating an appeal). A March 2008 statement of the case (SOC) continued to deny service connection for a psychiatric disability and an increased rating for his right hip condition. See also June 2008 Notification Letter (notifying the Veteran of this denial and enclosing the SOC and instructions on perfecting his appeal to the Board). However, the Veteran did not perfect his appeal. See 38 C.F.R. §§ 20.200, 20.202, 20.302 (2015) (setting forth requirements and time limits for perfecting an appeal to the Board). A March 2008 rating decision granted entitlement to service connection for a right knee disability and assigned a 10 percent rating effective January 27, 2006. See January 2006 Statement in Support of Claim (VA Form 21-4138) (indicating the Veteran's assertion that service connection was warranted for a right knee disability). A June 2013 rating decision, in pertinent part, granted an increased, 20 percent rating for the Veteran's low back strain, effective October 2, 2012. See October 2012 Veteran's Supplemental Claim for Compensation (VA Form 21-526b). That decision additionally denied entitlement to service connection for sleep apnea and confirmed and continued the previous November 2006 denial of entitlement to service connection for a psychiatric disorder. See id. (asserting entitlement to service connection for bipolar disorder); December 2012 Veteran's Supplemental Claim for Compensation (VA Form 21-526b) (asserting entitlement to service connection for sleep apnea). In a statement received by the RO later that month, the Veteran requested reconsideration of the RO's decision, asserting that his low back disability was more severe than reflected in the ratings assigned, and maintaining that service connection was warranted for sleep apnea and a psychiatric disorder. See June 2006 Letter from the Veteran; August 2013 Fully Developed Claim (VA Form 21-526EZ) (also requesting reconsideration of the denial of service connection for a psychiatric disability). In this regard, the Board notes that a claim becomes final and subject to a motion to reopen only after the period for appeal has run. See 38 C.F.R. § 20.302 (2015). As such, any interim submissions before finality attached for the June 2013 rating decision must be considered by VA as part of the Veteran's underlying claim. See 38 C.F.R. § 3.156(b) (2015); Charles v. Shinseki, 587 F.3d 1318, 1323 (Fed. Cir. 2009); Jennings v. Mansfield, 509 F.3d 1362, 1368 (Fed. Cir. 2007); see also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Consequently, the June 2013 decision denying a rating in excess of 20 percent for the service-connected low back strain, denying entitlement to service connection for sleep apnea, and confirming and continuing the previous November 2006 denial of entitlement to service connection for a psychiatric disorder is not final and remains on appeal. Subsequently, in June 2013, the Veteran filed an application for TDIU. See June 2013 Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940) (asserting that his service-connected disabilities prevented him from working); November 2013 Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940) (stating that that he last held full time employment in June 2013, at which time he became too disabled to work). Later, in August 2013, the Veteran initiated claims for increased ratings for his service-connected right ankle and knee disabilities, and additionally claimed entitlement to service connection for disabilities affecting his left hip, knee, and ankle. See August 2013 Fully Developed Claim (VA Form 21-526EZ) and Accompanying Documentation. A January 2014 rating decision, in pertinent part, granted an increased 10 percent rating for the Veteran's right ankle sprain residuals, effective August 22, 2013. Additionally, that decision denied a rating in excess of 30 percent for the right hip disability, denied a rating in excess of 10 percent for the right knee disorder, denied service connection for disorders of the left ankle and hip, confirmed and continued the previous January 2002 denial of service connection for a left knee disability, and denied entitlement to a TDIU. See January 2014 Rating Decision. Finally, that decision also denied a rating in excess of 20 percent for lumbar strain, denied service connection for sleep apnea, and confirmed and continued the previous November 2006 denial of service connection for a psychiatric disorder. See id. In March 2014, the Veteran disagreed with the RO's January 2014 decision. See March 2014 Notice of Disagreement (VA Form 21-0958). See also 38 C.F.R. §§ 20.200, 20.201, 20.302. In an April 2014 rating decision, the RO granted an earlier effective date of June 14, 2013 for the 10 percent rating for the Veteran's right ankle sprain residuals. Nevertheless, in a simultaneously issued SOC, the RO denied ratings in excess of 10 percent for the right ankle sprain residuals, in excess of 30 percent for the right hip iliotibial band syndrome, in excess of 10 percent for right knee iliotibial band syndrome, and in excess of 20 percent for lumbar strain; denied service connection for sleep apnea, a psychiatric disability, and disorders of the left ankle, knee, and hip; and denied entitlement to a TDIU. By an April 2014 Substantive Appeal (VA Form 9), the Veteran perfected an appeal as to the above-listed issues. See 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302. As concerning his claimed psychiatric disability, the Board notes that the record reflects various diagnostic impressions, including bipolar disorder, depression, and unspecified personality disorder. Because the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim and reported symptoms and all other information of record, the Board has recharacterized this claim more broadly to encompass all psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Furthermore, although the RO reopened the previously denied claims of entitlement to service connection for a left knee disorder and a psychiatric disability, the Board must independently decide whether the Veteran has submitted new and material evidence to reopen the claims. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Jackson v. Principi, 265 F.3d 1366 (Fed Cir 2001) ("Thus, the statutes make clear that the Board has a jurisdictional responsibility to consider whether it was proper for a claim to be reopened...."). In October 2015, the Veteran, his spouse, and his parents offered testimony at a Board videoconference hearing. A transcript of that hearing is of record. This appeal was processed using the Veterans Benefits Management System (VBMS) electronic claims processing system. Moreover, a review of the Virtual VA paperless claims processing system reveals additional records pertinent to the present appeal. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for sleep apnea; entitlement to increased ratings for the right ankle sprain residuals, right hip iliotibial band syndrome, right knee iliotibial band syndrome, and lumbar strain; and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A January 2002 rating decision denied the Veteran's claim of entitlement to service connection for a left knee disorder. The Veteran was notified of this decision and of his appellate rights, but did not appeal the decision. 2. The additional evidence received since that last final decision relates to an unestablished fact necessary to substantiate the service connection claim for a left knee disorder. 3. A November 2006 rating decision denied the Veteran's claim of entitlement to service connection for a psychiatric disorder. The Veteran was notified of this decision and of his appellate rights and initiated an appeal of this decision; however, he did not perfect an appeal. 4. The additional evidence received since that last final decision relates to an unestablished fact necessary to substantiate the service connection claim for a psychiatric disability. 5. The Veteran's has disorders of the left hip, left knee and left ankle that had their onset during active service. 6. The Veteran's acquired psychiatric disability had its onset during active service. CONCLUSIONS OF LAW 1. The RO's January 2002 rating decision denying the Veteran's claim of entitlement to service connection for a left knee disorder is final and binding based on the evidence then of record. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.104, 3.160, 20.200, 20.201, 20.202, 20.302, 20.1103 (2015). 2. New and material evidence has been received since that decision to reopen the service connection claim for a left knee disorder. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2015). 3. The RO's November 2006 rating decision denying the Veteran's claim of entitlement to service connection for a psychiatric disorder is final and binding based on the evidence then of record. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.104, 3.160, 20.200, 20.201, 20.202, 20.302, 20.1103 (2015). 4. New and material evidence has been received since that decision to reopen the service connection claim for a psychiatric disorder. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2015). 5. The criteria for service connection for a left hip disorder have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 6. The criteria for service connection for a left knee disorder have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 7. The criteria for service connection for a left ankle disorder have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). 8. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties To the extent that the previously denied claims on appeal are herein reopened, and moreover, since the reopened claims of entitlement to service connection for a psychiatric disability and a left knee disorder, as well as the additional claims of entitlement to service connection for disorders of the left hip and ankle, are being granted, discussion of whether VA has met its duties of notification and assistance under the Veterans Claims Assistance Act of 2000 ("VCAA") as concerning these claims is not required, and deciding the appeal at this time is not prejudicial to the Veteran. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). See also Vogan v. Shinseki, 24 Vet. App. 159, 163 (2010) (observing that an error that does not affect the outcome of a case is not prejudicial); Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009). II. New and Material Evidence The Veteran petitions to reopen the previously denied service connection claims for a left knee disorder and an acquired psychiatric disability. For the following reasons, the Board finds that reopening is warranted. (a) Left Knee Disorder As noted in the introduction above, service connection for a left knee disorder was denied on the merits in a January 2002 rating decision. A letter dated that same month notified the Veteran of the decision and of his appellate rights, in accordance with 38 C.F.R. § 19.25 (2015). He did not appeal. See 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302 (setting forth requirements and time limits for initiating and perfecting an appeal). Moreover, new and material evidence was not received within one year of the January 2002 rating decision; the evidence on which the reopening of these claims is based is not dated until several years later, as shown below. See 38 C.F.R. § 3.156(b); Young v. Shinseki, 22 Vet. App. 461, 466 (2009); see also Evans v. Brown, 9 Vet. App. 273, 282-3 (1996) (providing that new and material evidence must have been associated with the file since the last prior final denial of the claim, whether the denial was on the merits or on procedural grounds). Accordingly, this rating decision is final, and new and material evidence is therefore required to reopen the claim. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.156(a); 20.1103 (2015). New and material evidence has been received concerning the issue of entitlement to service connection for a left knee disability in the form of a January 2014 VA general medical examination indicating that his left lower extremity pathology was the result of "direct overuse or injury to that particular area" and originated "in the 1990s," so around the time of his active service. At the time of the January 2002 rating decision, evidence linking his claimed left knee disorder with an in-service event or injury was not of record. Accordingly, this medical evidence relates to an unestablished fact necessary to reopen the claim and raises a reasonable possibility of establishing service connection. See 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110, 117-121 (2010). Therefore, reopening is warranted. (b) Acquired Psychiatric Disability Service connection for a psychiatric disability, claimed as bipolar disorder, was denied on the merits in a November 2006 rating decision. The Veteran was notified of this decision and his appellate rights in a letter dated the following month, in accordance with 38 C.F.R. § 19.25. See December 2006 Notification Letter. The Veteran disagreed with this determination in January 2007, and the RO issued a March 2008 SOC, which continued to deny the claim. See 38 U.S.C.A. § 7105(a); 38 C.F.R. §§ 20.200, 20.201, 20.302. See also June 2008 Notification Letter (notifying the Veteran of this denial and enclosing the SOC and instructions on perfecting his appeal to the Board). However, the Veteran did not file a substantive appeal within 60 days of the date of notification of the March 2008 SOC. See 38 C.F.R. §§ 20.200, 20.202, 20.302(b). Moreover, new and material evidence was not received within one year of the November 2006 rating decision; rather, the evidence on which the reopening of this claim is based is not dated until several years later, as shown below. See 38 C.F.R. § 3.156(b); Young, 22 Vet. App. at 466; see also Evans, 9 Vet. App. at 282-3. Accordingly, the November 2006 rating decision is final, and new and material evidence is required to reopen the claim. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 3.156(a); 20.200, 20.302, 20.1103. New and material evidence has been received concerning the issue of entitlement to service connection for a psychiatric disability in the form of testimony from the Veteran and his parents indicating that his psychiatric symptoms had their onset during his active service. See October 2015 Board Hearing Testimony. Additionally, medical evidence has been associated with the claims file reflecting the professional opinion of the Veteran's VA treating psychiatrist that "it is as likely as not that his [psychiatric] illness began during years of military duty." See June 2013 VA Psychiatry Clinic Note Addenda. At the time of the November 2006 rating decision, the record did not contain definitive lay and medical statements associating his psychiatric disability with his active service. Accordingly, this evidence relates to an unestablished fact necessary to reopen the claim, and raises a reasonable possibility of establishing service connection. See 38 C.F.R. § 3.156(a); Shade, 24 Vet. App. at 117-121. Therefore, reopening is warranted. III. Service Connection Service connection means that a Veteran has a current disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or 'medical nexus' between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004)); see 38 C.F.R. § 3.303(a). (a) Left Hip, Knee, and Ankle Disorders On VA orthopedic examination in January 2014, the Veteran was diagnosed with left hip strain, left knee strain, and left ankle strain. See January 2014 VA General Medical Conditions Disability Benefits Questionnaire (DBQ); January 2014 VA Ankle Conditions DBQ; January 2014 VA Knee and Lower Leg Conditions DBQ; January 2014 VA Hip and Thigh Conditions DBQ. Further, the December 2001 VA orthopedic examiner indicated that the Veteran's left lower extremity symptoms were unrelated to his right lower extremity pathology and were instead the result of the type of "vigorous physical work, which he had when he was jumping out of airplanes and doing other heavy physical work" during service. These symptoms, the examiner explained, are "frequent in ex-airborne veterans." See December 2001 VA Joints Examination Report. The January 2014 VA orthopedic examiner echoed these findings, noting that the Veteran's diagnosed left hip, ankle, and knee strain were "more likely a result of direct overuse or injury to that particular area" rather than the disabilities affecting his right lower extremity, and emphasizing the Veteran's report that his left lower extremity symptoms in his hip, knee, and ankle had their onset during his period of active service. See January 2014 VA General Medical Conditions DBQ ("The Veteran reported symptoms for these conditions began in the 1990s."). See also Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge); Layno v. Brown, 6 Vet. App. 465 (1994) (holding that competent testimony is limited to that which the witness has actually observed, and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses, that which is heard, felt, seen, smelled or tasted); Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay statements are competent to establish the presence of observable symptomatology); see, too, Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Importantly, as indicated in the findings put forth by the Veteran's various VA examination providers, since he separated from active service in 1997, the Veteran's various physical limitations, including his service-connected low back and right lower extremity conditions, have prevented him from engaging in such "vigorous physical activity" as to result in the type of "direct overuse . . . injury" that would cause his current left hip, knee, and ankle strain. See January 2014 VA General Medical Conditions DBQ; December 2001 VA Joints Examination Report (finding that the Veteran's "right lower extremity condition[s] . . . may have actually spared [the left lower extremity] to some extent since the veteran has refrained from vigorous physical work, which he had when he when he was jumping out of airplanes and doing other heavy physical work" in service). Thus, when considered in the aggregate, the medical examination reports foreclose the possibility of post-service incurrence of the left lower extremity pathology and endorse an etiological relationship between the currently diagnosed left hip, knee, and thigh disabilities and the physical rigors of the Veteran's airborne service. In this regard, the Veteran's Form DD 214 documents his receipt of the parachutist badge, and the Veteran has reported engaging in repeated training jumps during his active service. See Washington, 19 Vet. App. 362. The Board therefore finds that the Veteran experienced the type of repetitive left lower extremity trauma and overuse injury described by the VA examiners, as such injuries are consistent with the circumstances of his service. See 38 U.S.C.A. § 1154(a) (stating that, "in each case where a veteran is seeking service-connection for any disability due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence"). Accordingly, given the repeated left lower extremity trauma experienced during his active service as a result of his airborne training, considering the currently diagnosed left hip, knee, and ankle disorders, in light of the Veteran's competent and credible assertions concerning the onset of his left lower extremity pathology, in view of the medical evidence of record attributing the Veteran's left hip, knee, and ankle strain to his parachute jumps during active service, and in the absence of any medical evidence to the contrary, the Board resolves reasonable doubt in the Veteran's favor and finds that the evidence supports a grant of entitlement to service connection for a disorders of the left hip, left knee, and left ankle. 38 C.F.R. §§ 3.102, 3.303. See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). (b) Acquired Psychiatric Disability The Veteran also asserts that he has a psychiatric disability that is related to his active service. Specifically, he asserts that his current psychiatric symptomatology, including racing thoughts, uncontrolled anger, reckless behavior, poor decision making, and alternating periods of mania and depression, first manifested during active service and has continued since that time. See, e.g., October 2015 Board Hearing Testimony. The medical evidence of record reflects multiple psychological diagnostic impressions, including bipolar disorder, depression, and unspecified personality disorder. Further, although the Veteran's STRs are silent for complaints of or treatment for any psychiatric conditions, the Veteran testified that he experienced progressively worsening psychiatric symptoms, including racing thoughts, uncontrolled anger, reckless behavior, poor decision making, and alternating periods of mania and depression, during his active service. See October 2015 Board Hearing Testimony. See also Washington, 19 Vet. App. 362 (A Veteran is competent to report what occurred in service because testimony regarding first-hand knowledge of a factual matter is competent). He additionally asserted that he currently exhibits the same psychiatric symptomatology and that he has experienced these symptoms without interruption since his active duty service. See Layno, 6 Vet. App. at 470. As the alleged symptoms are lay-observable, the Board accepts as competent the Veteran's assertion regarding his in-service symptomatology. See Jandreau, 492 F.3d at 1377; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Additionally, his assertions regarding this are supported by testimony from his parents, who confirm the onset of his symptoms during his active service, and his spouse, who confirms his current psychiatric manifestations. See Barr, 21 Vet. App. 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). Thus, the Board finds his testimony regarding the in-service onset of his psychiatric symptomatology to be credible. Jandreau, 492 F.3d at 1377 n.4; Baldwin v. West, 13 Vet. App. 1 (1999). The Veteran and his parents have credibly reported the onset of his psychiatric symptoms during his active service, and he and his spouse have confirmed the continuity of his psychiatric symptomatology since that time. There is no competent medical evidence of record refuting this assertion. Rather, the Veteran's post-service VA psychiatric treatment provider has related his psychiatric symptomatology to his active service. Specifically, in a June 2013 opinion, his VA treating psychiatrist stated that, based on the Veteran's reported history and her familiarity with and treatment of the Veteran, "it is as likely as not that his [psychiatric] illness began during years of military duty." See June 2013 VA Psychiatry Clinic Note Addenda. Accordingly, the overall weight of the evidence supports a link between the Veteran's current acquired psychiatric disorder and his period of service. Therefore, service connection for an acquired psychiatric disorder is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. ORDER New and material evidence having been received, the issue of entitlement to service connection for a left knee disorder is reopened. New and material evidence having been received, the issue of entitlement to service connection for a psychiatric disorder is reopened. Entitlement to service connection for a left hip disability is granted. Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for a left ankle disability is granted. Entitlement to service connection for an acquired psychiatric disorder is granted. REMAND Unfortunately, the remaining claims on appeal must be remanded. While the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the claims so that the Veteran is afforded every possible consideration. 38 U.S.C.A. § 5103A(a) (West 2014); 38 C.F.R. § 3.159(c), (d) (2015). Initially, the Board notes that the Veteran reported at his October 2015 Board hearing that is in receipt of Social Security Administration (SSA) benefits, the award of which is based, at least in part, on consideration of his service-connected disabilities, including his now-service-connected psychiatric condition. Although the Veteran submitted several documents from the SSA during the course of his appeal, including the June 2014 Notice of Decision awarding disability benefits, a review of the claims file does not show that VA has attempted to obtain any of the Veteran's SSA records as part of his claim. In this regard, VA has an obligation to obtain copies of all Social Security decisions and the records underlying those decisions where such records are potentially relevant to the claims. See Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). Therefore, as the record reflects SSA records that may be outstanding and may be pertinent to the Veteran's claims, the Board must remand the remaining claims in order to obtain those records. See id.; see also 38 C.F.R. § 3.159(c)(2) and (3) (2015). As concerning the Veteran's claim of entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities, the Veteran specifically asserts that he developed this disability as the result of weight gain due to his inability to exercise due to his service-connected orthopedic disabilities. See December 2012 Statement in Support of Claim (VA Form 21-4138). He has not, as yet, been afforded a VA examination for an opinion as to the likely etiology of this condition. See 38 U.S.C.A. § 5103A(d)(2) (West 2014); 38 C.F.R. § 3.159(c)(4)(i) (2015); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (reflecting that VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim). Given his contentions, and in light of VA's duty to assist, the Board finds the evidence of record meets the low threshold of an "indication" that the claimed disabilities have a causal connection or association with service. See McLendon, 20 Vet. App. at 83. Therefore, on remand, he should be afforded an appropriate VA examination for an opinion as to the likely etiology of his sleep apnea. Additionally, the issue of entitlement to TDIU is dependent on the outcome of this claim, as the assignment of ratings to the claim granted herein, as well as any potential grant of the remanded issues, could result in a higher overall disability rating. See 38 C.F.R. § 4.16(a) (2015); see also Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are 'inextricably intertwined' when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Therefore, after the AOJ has assigned ratings to the newly granted service connection claims and after it has completed the additional development requested herein with regard to the remanded service connection and increased rating claims, the AOJ is instructed to afford the Veteran an examination to identify all limitations imposed on him as a consequence of his service-connected disabilities, and for an opinion concerning the impact of the service-connected disabilities, to include in the aggregate, on his ability to secure and follow a substantially gainful occupation. In this regard, the Board notes that the examination reports and opinions adduced during the pendency of the appeal do not explicitly address the Veteran's level of education, prior work experience, or training, and do not take into consideration the combined effect of his service connected disabilities on his ability to obtain or maintain substantially gainful activity. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159, 4.18, 4.19. But see Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (In a TDIU determination, "VA's duty to assist does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities."); see also Floore v. Shinseki, 26 Vet. App. 376, 381 (2013) (holding that, in a multiple-disability TDIU determination, "the need for a combined-effects medical examination report or opinion . . . is to be determined on a case-by-case basis, and depends on the evidence of record" at the time the decision). Therefore, after all appropriate development has been completed, the issue of TDIU should be readjudicated in light of the additional evidence, to include consideration of the provisions of 38 C.F.R. § 4.16(a) and (b), as applicable. Finally, as the claims are being remanded, the RO/AMC should also obtain any outstanding VA treatment records and associate them with the electronic claims file. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Implement the Board's decision awarding service connection for an acquired psychiatric disability, a left hip disorder, a left knee disorder, and a left ankle disorder. 2. Request from the Social Security Administration all records pertinent to the Veteran's claim for benefits, as well as medical records relied upon concerning that claim. If the search for such records has negative results, the RO/AMC should place a statement to that effect in the Veteran's claims file. 3. Make arrangements to obtain any outstanding VA treatment records and associate them with the electronic claims file. 4. Thereafter, schedule the Veteran for an appropriate VA examination to determine the etiology of his diagnosed sleep apnea. The Veteran's claims file, including a copy of this remand, must be made available to and reviewed by the hearing examiner. The examination report must reflect that such a review was undertaken. After reviewing the file, obtaining a complete medical history of the Veteran's claimed conditions, and examining the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea had its clinical onset during active service or is related to any in-service disease, event, or injury. If the VA examiner finds that the Veteran's currently diagnosed sleep apnea was less likely than not caused by or incurred in his active service, then the examiner is asked to provide an opinion as to whether it is at least as likely as not (at least a 50-50 percent probability) that the diagnosed sleep apnea was either (a) caused by, or (b) aggravated by (that is, made permanently worse by) any service-connected disability (i.e. the lumbar strain, right hip iliotibial band syndrome, right knee iliotibial band syndrome, and right ankle sprain residuals; as well as the now-service-connected left hip disability, left knee disability, left ankle disability, and acquired psychiatric disorder). In providing this opinion, the examiner should specifically address the Veteran's contentions that his sleep apnea is impacted by his obesity, which is the result of his inability to exercise due to his service-connected orthopedic disabilities. The examiner should address the impact of the Veteran's physical condition, if any, upon the sleep apnea condition. All examination findings, along with the complete explanation for all opinions expressed, must be set forth in the examination report. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 5. Also, schedule the Veteran for an appropriate VA examination, to be conducted, if possible, by a vocational rehabilitation specialist, to evaluate the issue of entitlement to a TDIU. In conjunction with the examination, the claims file and a complete copy of this REMAND must be made available to and reviewed by the examiner. The examination report should indicate that this has been accomplished. The examiner should elicit from the Veteran his complete educational, vocational, and employment history and should note his complaints regarding the impact of his service-connected disabilities on his employment. After a full examination and review of the claims file, the examiner should identify all limitations imposed on the Veteran as a consequence of his service-connected disabilities (i.e., lumbar strain, right hip iliotibial band syndrome, right knee iliotibial band syndrome, and right ankle sprain residuals, left hip strain, left knee strain, left ankle strain, and acquired psychiatric disorder, and any pending disabilities for which service connection is granted on remand) and opine as to the impact of the service-connected disabilities, to include in the aggregate, on his ability to secure and follow a substantially gainful occupation. The examiner(s) must provide a comprehensive report including complete explanation for all opinions and conclusions reached, taking into account, and citing where appropriate, the evidence in the record, including the Veteran's reports of his history, his current symptomatology, and all associated functional and occupational limitations found. 6. Following completion of the above directive, review the claims file to ensure compliance with this remand. If any examination report does not include adequate responses to the specific opinions requested, it must be returned to the examiner for corrective action. 7. After completing all of the above, and any additional development deemed warranted, readjudicate the claims on appeal, including the issue of entitlement to TDIU. If the benefits sought are not granted, the Veteran and his attorney must be furnished a supplemental statement of the case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 2014). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs