Citation Nr: 1612118 Decision Date: 03/25/16 Archive Date: 03/29/16 DOCKET NO. 12-12 097 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an increased disability rating (or evaluation) in excess of 20 percent for service-connected residuals, status post incarcerated rectus sheath hernia repair (ventral hernia residuals). 2. Entitlement to service connection for major depressive disorder as secondary to service-connected hernia residuals. 3. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from October 1981 to June 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction over this claim is now with the RO in San Juan, the Commonwealth of Puerto Rico. This appeal was processed using both the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). Accordingly, any future review of this case should take into consideration the existence of this electronic record. The issue of entitlement to compensation for an episode of ventral hernia strangulation under 38 U.S.C.A. § 1151 has been raised by the record in December 2007 and March 2014 statements, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. For the entire increased rating period, the residuals of a ventral hernia include a healed ventral hernia and post-operative wounds with weakening of the abdominal wall and indication for a supporting belt; it does not include a large post-operative ventral hernia that is not well-supported by belt under ordinary circumstances. 2. The Veteran has a current disability of major depressive disorder. 3. The Veteran is service connected for ventral hernia residuals. 4. The current major depressive disorder is not caused by, or increased in severity beyond the natural progress of the disease by, the service-connected ventral hernia residuals. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for residuals of a ventral hernia have not been met or more nearly approximated for the entire increased rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.114, Diagnostic Code 7339 (2015). 2. The criteria for service connection for major depressive disorder, as secondary to service-connected ventral hernia residuals, are not met. 38 U.S.C.A. §§ 1101, 1131, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In this case, concerning the appeal for an increased disability rating for ventral hernia residuals, the RO provided a timely notice letter to the Veteran in December 2009. The letter notified the Veteran of what information and evidence should be submitted to substantiate a claim for an increased rating. Additionally, the December 2009 letter provided the general criteria for the assignment of an effective date and initial rating. Concerning the appeal for service connection for major depressive disorder, in a timely letter dated in December 2009, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate claim for service connection for major depressive disorder on a secondary basis, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The December 2009 letter also included provisions for disability ratings and for the effective date of the claim. VA also satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA treatment records, VA examination reports, and lay statements. The Veteran underwent VA examinations in March 2010 and November 2014 to assist in determining the current severity of the service-connected ventral hernia residuals. The Board finds that the VA examination reports are thorough and adequate and provide a sound basis upon which to base a decision with regard to the issue adjudicated below. The VA examiners personally interviewed and examined the Veteran, including eliciting a history, conducted a physical examination, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes related to the service-connected ventral hernia residuals. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issue of an increased rating for ventral hernia residuals has been met. 38 C.F.R. § 3.159(c)(4). The Veteran was also afforded an opportunity for a VA medical examination in connection with the claim for service connection for major depressive disorder in January 2010. 38 C.F.R. § 3.159(c)(4) (2015). The Board finds that the January 2010 VA examination is adequate with regard to the claim for service connection for major depressive disorder. The opinion rendered in the January 2010 VA examination pertaining to major depressive disorder considers all the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale for the opinion stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issue of service connection for major depressive disorder on a secondary basis has been met. 38 C.F.R. § 3.159(c)(4). As such, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issues adjudicated herein. Mayfield, 444 F.3d at 1328. Hence, no further notice or assistance is required to fulfill VA's duties to notify and assist the Veteran in the development of the appeal. Increased Rating for Ventral Hernia Residuals Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2015). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two disability ratings shall be applied, the higher rating is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has reviewed all the evidence in the Veteran's electronic file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The service-connected residuals of a ventral hernia are rated at 20 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7339. Under Diagnostic Code 7339, pertinent in this case, a 20 percent rating is warranted for a small postoperative ventral hernia which is not well supported by a belt under ordinary conditions, or a healed ventral hernia or postoperative wound with weakening of the abdominal wall and indications for a supporting belt. A 40 percent rating is warranted for a large postoperative ventral hernia which is not well supported by belt under ordinary conditions. 38 C.F.R. § 4.114, Diagnostic Code 7339. Having carefully considered the lay and medical evidence of record, the Board finds that the ventral hernia residuals more nearly approximates a healed ventral hernia and post-operative wounds with weakening of the abdominal wall and indication for a supporting belt. In a March 2010 VA examination, the VA examiner indicated that there was a "good heal" of the traditional open repair of the ventral hernia and that there were no hernias present at the time of the examination. In the November 2014 VA examination report, the Veteran reported ventral pain upon bending, pushing, pulling, lifting or carrying; as such, he is still using a belt. Upon physical examination, the VA examiner indicated that the Veteran had healed postoperative ventral hernia repair and healed postoperative wounds with weakening of abdominal wall. The VA examiner also noted that there an indication for a supporting belt and that the hernia can be well supported by truss or belt. In short, a hernia was not found during the March 2010 VA hernia examination. While the Veteran reported ventral pain during the November 2014 VA examination, the VA examiner indicated that the hernia is well-supported by a belt. Here, the evidence does not demonstrate residuals of a ventral hernia such as large postoperative ventral hernia which is not well supported by belt under ordinary conditions. For these reasons, the Board finds that, for the entire increased rating period, the criteria for a schedular rating under Diagnostic Code 7339 in excess of 20 percent for residuals of a ventral hernia have not been met or more nearly approximated. 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7339. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's appeal, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Additionally, the Board finds no other applicable diagnostic codes which would afford the Veteran a higher disability rating. See Schafrath, 1 Vet. App. at 589. In this regard, in a May 2012 rating decision, the Veteran was awarded a separate 10 percent rating for a residual scar associated with the service-connected ventral hernia residuals. The Veteran did not initiate a timely appeal of the May 2012 determination, and it became final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2015). Extraschedular Consideration The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. The Board finds all that the symptomatology and impairment caused by the Veteran's service-connected ventral hernia residuals are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. Diagnostic Code 7339 specifically addresses postoperative ventral hernias and provides a series of disability ratings based on common residual symptoms and impairment. Here, the ventral hernia residuals include a healed ventral hernia and post-operative wounds with weakening of the abdominal wall and indication for a supporting belt. The Veteran has also reported ventral pain. While ventral pain is not a symptom listed in Diagnostic Code 7339, the evidence generally shows a healed hernia with residual symptoms that are well supported by a supporting belt. For these reasons, the Board finds that the schedular rating criteria are adequate to rate the service-connected residuals of a ventral hernia and no extraschedular referral is warranted. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the symptoms reported by the Veteran regarding the service-connected ventral hernia residuals are specifically contemplated by the criteria discussed above, including the effect of the Veteran's symptoms on his occupation and daily life. In the absence of exceptional factors associated with ventral hernia residuals, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Also, the issue of a TDIU, which is another form of extraschedular rating with different criteria, is addressed in the Remand section below. Service Connection for Major Depressive Disorder Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 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, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In this case, major depressive disorder is not a "chronic disease" listed under 38 C.F.R. § 3.309(a) (2015); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability that is proximately due to or the result of a service-connected disability. Service connection may also be granted for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran contends that the current major depressive disorder is secondary to the service-connected hernia residuals. Specifically, the Veteran asserts that the major depressive disorder is caused by abdominal pain that he believes is associated with the service-connected ventral hernia residuals. See December 2009 Claim; see also April 2010 Notice of Disagreement. Because the Veteran has not contended that the major depressive disorder had its onset during active service, and the evidence of record does not otherwise indicate that the major depressive disorder was causally or etiologically related to service, the Board need not address whether service connection is warranted for major depressive disorder on a direct basis. See Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008) (VA must consider the possible theories of entitlement raised by the claimant or the evidence of record). Initially, the Board finds that the Veteran has been diagnosed with major depressive disorder. See January 2010 VA Mental Disorders Examination; see also VA Treatment Records. The Board next finds that the Veteran is service connected for ventral hernia residuals. Service connection for residuals, status post incarcerated rectus sheath hernia repair, was established in an August 2007 rating decision with an effective date of October 27 2006. After reviewing all the lay and medical evidence of record, the Board finds that the weight of the evidence demonstrates that the Veteran's major depressive disorder is not proximately due to, or permanently worsened in severity beyond the natural progression (aggravated) by, the service-connected ventral hernia residuals. The Veteran was afforded a VA examination in January 2010. The January 2010 VA examiner opined that the depressive disorder is not related to, caused by, or secondary to the service-connected ventral hernia residuals. Significantly, the January 2010 VA examiner explained that both (the major depressive disorder and the ventral hernia residuals) are "independent of" the other. As additional rationale, the VA examiner further explained that the Veteran had hernia repair while in active service and surgery was performed in May 1982 with no evidence in the record of any complication pre or post-procedure. The VA examiner noted that the record reflects that the Veteran had economic problems in 2009 when he was assessed by VA psychiatry and admitted in November 2009. While the VA examiner's opinion in January 2010 regarding the relationship between the Veteran's major depressive disorder and the service-connected ventral hernia residuals more directly addresses causation, and does not include the words "aggravation" or "permanently worsened in severity," the rationale of the opinion, which includes that the major depressive disorder and the ventral hernia residuals are "independent of" each other, identifies the more likely source of the depression, that the abdominal pain is not caused by the hernia residuals, and the source of the pain in non-service-related obesity, constitutes an opinion that, by necessary inference, is an opinion that the ventral hernia residuals has no effect on the major depressive disorder, either to cause the major depressive disorder or to worsen it. See Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) (recognizing that the "evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder"). Even the Veteran attempts to relate the depressive disorder to (non-service-related) abdominal pain; however, pain is not part of the service-connected ventral hernia residuals. The Board finds that the January 2010 VA examiner's opinion in this case is distinguishable from the opinion found inadequate in El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (finding a Board's VA examination adequacy finding clearly erroneous where the claimant alleged an aggravation theory of entitlement, but the VA examiner's opinion focused solely on direct causation). In El-Amin, the United States Court of Appeals for Veterans Claims held that a VA examiner's finding that the disability in question was caused by factors other than a service-connected disability, while not addressing the effect of the service-connected disability, did not address the question of whether the claimed disability was nevertheless aggravated by the service-connected disability, irrespective of whether there was a causal relationship. Unlike the examiner's opinion in El-Amin, in this Veteran's case, the January 2010 VA examiner's opinion was not based primarily on the fact that the claimed major depressive disorder was caused by other, non-service-connected factors mixed with no opinion as to the causative or contributory effect of the service-connected disability; rather the January 2010 VA examiner in this Veteran's case necessarily addressed the question of whether the major depressive disorder was aggravated by the service-connected disability (ventral hernia repairs) by stating an assessment of "independent" conditions, identifies the more likely source of the depression, assesses that the abdominal pain is not caused by the hernia residuals, and assesses that the source of the abdominal pain in non-service-related obesity. See 38 C.F.R. § 4.14 (2015). The necessary inference from the VA examiner's assessment, that the major depressive disorder and the ventral hernia residuals are independent of each other, supported by a rationale that the source of the reported pain that the Veteran attributes as the cause of the depression is non-service-related, is that there is no relationship (either causation or aggravation) between the two conditions. As there is medical opinion that the reported abdominal pain is of a non-service-related etiology, and the more likely etiology of such pain has been identified, this leaves no aggravating factors upon which an opinion could rely or upon which an adjudicative determination of aggravation could be rendered, as any such opinion or adjudication would violate the rule against pyramiding in violation of See 38 C.F.R. § 4.14 by erroneously attributing abdominal pain to a service-connected disability. The January 2010 VA examiner's opinion necessarily eliminates any suggestion of likelihood of relationship of any kind between major depressive disorder and ventral hernia residuals, either by way of causation or aggravation. The January 2010 VA examiner's medical opinion, that the major depressive disorder and the ventral hernia residuals are "independent of" each other, is contrary to the secondary relationship contended by the Veteran. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)). In short, although the January 2010 VA examiner did not use the word "aggravation" or similar language, the VA examiner's findings addressed both the question of causation and the question of aggravation. Consistent with the January 2010 VA examiner's opinion, VA treatment records also weigh against a finding that major depressive disorder is proximately due to, or aggravated by, the service-connected ventral hernia residuals. In a December 2009 VA psychiatric progress note, the treating psychiatrist noted that the Veteran related his anxiety to the constant pain on the abdomen where the umbilicus used to be before surgery to repair a ventral hernia, which occurred during military service. As the analysis in this Board decision demonstrates, and the medical opinion evidence supports, abdominal pain is not a current symptom associated with the service-connected ventral hernia residuals. Significantly, the VA psychiatrist indicated that the Veteran had difficulty understanding and accepting the fact that morbid obesity is behind the pain in the Veteran's abdomen. The VA psychiatrist explained to the Veteran, in simple terms, the nature of the problem (pain in the abdomen) and how eating healthily and exercising in a regular manner could help the Veteran reduce weight and, as a result, alleviate the pain. There are no other medical opinions of record that purport to relate the major depressive disorder to any service-connected disability. The January 2010 VA examiner concluded that the Veteran's service-connected ventral hernia residuals (which do not currently cause abdominal pain) did not cause or aggravate the major depressive disorder. A VA psychiatrist also related the Veteran's abdominal pain to non-service-related morbid obesity and explicitly excluded ventral hernia residuals as a cause of the abdominal pain. Thus, based on the most persuasive and probative evidence in this case, the Board finds that the major depressive disorder is not proximately due to, the result of, or aggravated by, the service-connected ventral hernia residuals. As such, secondary service connection for major depressive disorder, to include on the basis of aggravation, is not warranted. 38 C.F.R. § 3.310; Allen, supra. The Board acknowledges the Veteran's own contention that the major depressive disorder is secondary to the service-connected ventral hernia residuals, but finds that, under the facts of this case, as a lay person the contention is entitled to little probative weight as such a nexus question is medically complex. Such an opinion would require knowledge of both physical (abdominal) and psychological disorders, and the interaction between major depressive disorder and ventral hernias. Such opinion would further require an ability to differentiate between abdominal pain caused by morbid obesity from any ventral hernia residuals. As the Veteran is not competent to diagnose either major depressive disorder or a ventral hernia, he is likewise not competent to relate major depressive disorder to ventral hernia symptoms. See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (holding that "PTSD is not the type of medical condition that lay evidence . . . is competent and sufficient to identify"); Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that a conclusory generalized lay statement - that schizophrenia and anti-psychotic drugs to treat it had aggravated diabetes and hypertension - would not even suffice to meet the VCAA standard to trigger a VA examination or nexus opinion). Major depressive disorder is a psychiatrically complex disease process because of its multiple possible etiologies, the fact that it requires specialized testing to diagnose, that manifest symptomatology overlaps with other disorders, and the fact that there are internal and unseen system processes involved that are unobservable by the Veteran as a lay person. As a lay person, under the specific facts of this case, the Veteran has not been shown to have the knowledge, training, or experience to differentiate his symptoms and the possible etiologies of major depressive disorder, including non-service-related risk factors such as weight, or to opine as to the complex interaction between major depressive disorder (psychiatric disorder) with a ventral hernia (physiological disorder). See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (recognizing that evidence that pertains only to a physical or a psychiatric disorder, but not both, is not facially relevant); see also Moray v. Brown, 5 Vet. App. 211 (1993) (regarding causation of retinitis pigmentosa, veteran's testimony of aggravation of pre-existing disability in service was not competent evidence of aggravation, which was medical in nature). Here, the Board affords significant probative weight to the opinion of the VA examiner, who is a trained medical professional (psychiatrist), reviewed the relevant facts and medical history, examined the Veteran, opined that the Veteran's ventral hernia residuals did not cause or aggravate the major depressive disorder, and provided a rationale for the opinion. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for major depressive disorder on a secondary basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. As explained above, the Board does not reach the theory of direct service connection because the Veteran has not asserted that major depressive disorder was incurred in service, and has only consistently contended that major depressive disorder, diagnosed after service, is caused by the service-connected ventral hernia residuals. See December 2009 Claim; see also April 2010 Notice of Disagreement. ORDER For the entire increased rating period, an increased rating in excess of 20 percent for residuals, status post incarcerated rectus sheath hernia repair, is denied. Service connection for major depressive disorder as secondary to ventral hernia residuals is denied. REMAND TDIU A remand is required to ensure that there is a complete record upon which to decide the appeal of service connection for major depressive disorder and entitlement to a TDIU. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2014); 38 C.F.R. § 3.159(c), (d) (2015). During the pendency of this appeal, the Veteran has asserted that the service-connected ventral hernia residuals have prevented him from working. In a December 2014 statement (via VA Form 9), the Veteran asserted that the pain resulting from the service-connected ventral hernia residuals rendered him unemployable. A claim for a TDIU may be considered implicitly within a current increased rating claim. See Comers v. Peake, 552 F.3d 1362, 1367 (Fed. Cir. 2009) (a TDIU claim is "implicitly raised whenever a . . . veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating"); Rice v. Shinseki, 22 Vet. App. 447 (2009) (suggesting, in an effective date appeal, that an appeal for higher rating somehow includes a TDIU, or that a TDIU may arise from an increased rating claim, unless it is the veteran who raises the TDIU claim). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2015); VAOPGCPREC 75-91. A threshold requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a) is that, if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). Although the Veteran does not have at least one disability rated at 40 percent disabling with a combined rating at least 70 percent, the Board must also consider entitlement to a TDIU pursuant to 38 C.F.R. § 4.16(b). Here, however, the AOJ has not considered the Veteran's TDIU claim in light of the recent contentions. Therefore, remand is required to afford initial consideration of a TDIU by the AOJ. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Accordingly, the issue of entitlement to a TDIU is REMANDED for the following actions: 1. Provide the VCAA notice for the issue of TDIU. 2. After completion of the above and any additional development deemed necessary, to include obtaining an industrial or occupational assessment from a vocational or similar specialist, adjudicate the issue of a TDIU in light of all the evidence of record, considering additional occupational impairment caused by the service-connected ventral hernia residuals, along with all other service-connected disabilities. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs