Citation Nr: 1753527 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 11-02 262 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for left cubital tunnel and left carpal tunnel syndrome, to include as secondary to service-connected shell fragment wound. 2. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as due to asbestos exposure. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to November 12, 2013. 4. Entitlement to a rating in excess of 70 percent for PTSD from November 12, 2013. 5. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from April 1966 to April 1968. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from February 2010, April 2013, and January 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In March 2015, the Veteran was scheduled for the requested travel Board hearing. In a letter dated February 2015, the Veteran withdrew his request. Accordingly, the Board will proceed with an appellate decision on these matters. In July 2016, the Board issued a decision granting service connection for bilateral hearing loss and tinnitus, and remanded the remaining matters to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since returned to the Board for the purpose of appellate disposition. In compliance with the Board's remand instructions, Social Security Administration (SSA) records and outstanding VA records were obtained. The Veteran was also afforded a VA psychiatric examination and afforded the opportunity to submit additional lay evidence in support his claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board acknowledges that the Veteran has been awarded a combined 100 percent rating for a portion of the appeal period; however, this matter remains on appeal for the entire appeal period. In Bradley v. Peake, 22 Vet. App. 280, 294 (2008), the Court determined that a separate TDIU rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation under 38 U.S.C. § 1114(s). Thus, the Court reasoned, it might benefit the Veteran to retain the TDIU rating, even where a 100 percent schedular rating has also been granted. Accordingly, the Board will address whether entitlement to a TDIU is warranted. The issues of entitlement to service connection for left carpal tunnel and left cubital tunnel syndrome is addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A respiratory disorder, to include COPD, is not shown by the record. 2. Throughout the appeal period, the Veteran's PTSD has been productive of occupational and social impairment, with deficiencies in most areas, due to such symptoms as irritability, anger, and suicidal thoughts. 3. The Veteran meets the schedular requirement for TDIU, and the effects of his service-connected PTSD have rendered him unemployable. CONCLUSIONS OF LAW 1. The criteria for service connection for COPD are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for a 70 percent rating for PTSD prior to November 12, 2013, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.7, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for a rating in excess of 70 for PTSD from November 12, 2013, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.7, 4.130, Diagnostic Code 9411 (2017). 4. The criteria for an award of TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.16(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). However, 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a), and not to the claimed disability on appeal. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. Service connection may also be granted for a disease first 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). The Veteran contends that he is entitled to service connection for COPD, as related to asbestos exposure in service. The Veteran's service treatment records include no complaint, finding, or diagnosis with respect to the claimed COPD. On discharge examination in March 1968, the lungs and chest were found to be normal. Following service, a pulmonary function test dated in January 2008 reflects that the Veteran had poor effort due to coughing and claustrophobia. The result was "submaximal effort, suggestive restrictive pattern." A June 2009 chest x-ray reflects that COPD changes were suspected, but clinical correlation was needed. A November 2009 pulmonary clinic note reflects that he Veteran had a history of 2 years of cough with no prior history of pulmonary disease, chronic bronchitis, chronic sinusitis, or allergic rhinitis. Given the Veteran's history, exam, and imaging, his symptoms were most likely consistent with gastroesophageal reflux disease (GERD). On VA examination in January 2013, the examiner noted that, following the 2009 reports, the Veteran had not had further complaints of cough noted in progress notes. Also, the pulmonary function study and evaluation was not consistent with COPD. Therefore, the examiner indicated that the Veteran was not diagnosed with COPD, but rather GERD. SSA records reflect that the Veteran filed for disability noting a history of COPD; however, no medical records substantiating the diagnosis are included in these records. In sum, the record includes no diagnosis of COPD or other related respiratory disorder. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, where, as here, competent medical evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no disability, the Board does not reach the issue of whether the claimed disability is related to service. As a lay person, the Veteran is competent to report on that which she has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the record is devoid of any evidence showing a current respiratory disease or injury, and he has not provided any lay evidence that would suggest the existence of a disease or injury. The Board acknowledges the Veteran's contentions that he was exposed to asbestos during service related to his in-service duties. See VA's Adjudication Manual (M21-1), Part IV, Subpart ii, 1.I.3.a (accessed June 14, 2017) (explaining that claims based on asbestos exposure require a military occupational skill with exposure to asbestos sufficient to request an examination and a diagnosed disability that has been associated with in-service asbestos exposure); M21-1, Part IV, Subpart ii, 2.C.2.c (accessed June 14, 2017) (listing specific diseases that may result from exposure to asbestos). Again, as there is no disability, any additional development or discussion on the alleged asbestos exposure is not warranted. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. Increased Rating The Veteran also contends that he is entitled to an increased initial rating for the service-connected PTSD. Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). As staged ratings have already been assigned, the Board will address the propriety of the rating assigned at each stage. The Veteran's PTSD is rated as 30 and 70 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. This diagnostic code provides that PTSD is to be rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 30 percent rating is warranted for occupational and social impairment with an 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 a depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is assigned for 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. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir. 2013) the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Psychiatric examinations formerly include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). To the extent that the medical evidence reflects diagnoses of other psychiatric disorders, where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). A November 2009 VA treatment report reflects that the Veteran had symptoms of irritability, feeling low, crying spells, and poor sleep. He had nightmares 3-4 times per week, waking up in a sweat. On VA examination in November 2009, the Veteran reported that he could not sleep a full night's sleep. He also reported nightmares, depression, and interpersonal difficulties related to his prior marriages. He had no social life. The Veteran reported that he had worked as a carpenter superintendent for the last 7 years, but was laid off and had been retired for two weeks. No significant problems or time lost from work, secondary to psychiatric symptoms were noted. He was separated from his fifth spouse, and had one adult daughter than he had been estranged from for 20 years. He did express that his psychiatric symptoms had caused problems in his previous relationships. He had resided with his mother since his last separation. He golfed and fished for recreation. On mental status examination, there was no impairment of thought process or communication. The Veteran denied delusions or hallucinations. The Veteran made appropriate eye-contact and was cooperative. No inappropriate behavior was noted. He had transient suicidal thoughts, without a plan. He was alert and oriented. He denied memory loss or impairment. He denied obsessive or ritualistic behavior that interfered with routine activities. Rate and flow of speech was within normal limits. He denied panic attacks. Both depression and anxiety were noted. At times, he reported problems with "stupid decision making." He slept 3-4 hours of restless sleep a night. The examiner diagnosed PTSD, chronic, moderate and depressive disorder not otherwise specified. A GAF score of 55-60 was assigned. The examiner determined that the disability caused no significant impairment with work performance. There was moderate impairment in family role, in that he was separated from his fifth spouse and an estranged daughter. He had serious impairment in social and interpersonal functioning, as evidenced by disengagement from social activities, detachment from others, and restriction of affect. Activities of daily living remained intact. There was moderate impairment in recreation and leisure pursuits as evidenced by diminished interest/pleasure in activities and social isolation. On VA mental health treatment in March 2011, the Veteran reported increased alcohol usage and nightmares. No homicidal ideation, suicidal ideation, or psychosis was reported. On VA examination in November 2013, the Veteran reported restricted affect, anhedonia, flashbacks, episodes of uncontrolled anger and rage, episodes of anxiety and panic, social isolation, passive suicidal ideation, difficulty concentrating, sense of foreshortened future, fatigue, depressed mood, feelings of worthlessness and guilt. He reported few friends, limited leisure time activity, and a very limited social life. He retired from work as a construction superintendent in 2008. The examiner noted that the following symptoms applied to the Veteran's psychiatric disorder: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfered with routine activities, impaired impulse control, and neglect of personal appearance and hygiene. The examiner diagnosed PTSD, chronic, severe. A GAF score of 48 was assigned, reflecting serious symptoms and deficits in social, work, and personal functioning. The examiner found the disability to be productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, and/or mood. He found the Veteran likely unable to secure or maintain any kind of reasonable employment at this time. A December 2016 VA treatment report reflects that he was doing well and was happier since he recently married. He got 4-5 hours of sleep with medication. He enjoyed woodworking and spending time with his dog. He endorsed periods of depressed mood over recent months. A March 2017 VA mental health assessment reflects that the Veteran presented with good hygiene and grooming. His speech was of normal rate, tone, and volume. Affect was appropriate, reactive, and mood-congruent. He was depressed about his brother's illness but otherwise was "happy." There was no psychomotor agitation or retardation observed. Thought process was organized, logical, and goal-directed. Though content was negative for hallucinations, delusions, or paranoia. He denied suicidal or homicidal ideation. Insight and judgment were good. On VA examination in April 2017, the Veteran reported that he had been with his wife for several years, and they recently married in 2016. He expressed that his relationship with his wife was very good. He also had one living brother with whom he reported a good relationship. He denied having any friends, and spent most of his day at home. He said that the only social activity he tolerated was communicating with people at church on Sundays. With respect to work, the Veteran stopped working at age 63 due to physical problems and worsening PTSD symptoms. He stated that he frequently had personality conflicts and outbursts at work as a construction project manager. He denied other relevant occupational and educational history. Current symptoms included sleep disturbances, nightmares, fatigue, hypervigilance, exaggerated startle response, and avoidance of all stimuli associated with his combat experiences. His current depressive symptoms included daily sadness, anhedonia, and feelings of worthlessness, as well as increased appetite, reduced energy, and poor sleep. He reported one suicide attempt in 1978, and denied recent suicidal thoughts. He denied a history of perceptual disturbances. He took medication and was in a PTSD group 2 years ago, but was not in current therapy. On mental status examination, the examiner indicated that the following symptoms applied to the Veteran's diagnosis: depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. The Veteran was casually dressed and adequately groomed. Speech appeared normal. The Veteran was pleasant and cooperative and maintained good eye contact. Mood was described as "okay today," though his affect appeared dysphoric. There was no evidence of a formal thought disorder. The Veteran was oriented to person, place, time, and situation. Remote memory appeared to be grossly intact based upon the Veteran's ability to give what seemed to be an accurate social history. Working memory appeared somewhat impaired based on his inability to recall previously presented information, as the Veteran recalled only 2/3 words after five minutes. The Veteran did not accurately repeat a phrase. Simple auditory attention and concentration appeared limited based on his inability to solve a mental arithmetic problem. The Veteran was able to able to spell the word "world" forward, though he misspelled it backward. Abstract reasoning and social judgment appeared to be intact. Insight into the Veterans symptoms and situation and their impact on daily life was fair. The examiner diagnosed PTSD, and found the disability to be productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner indicated that the Veteran was not capable of maintaining steady work. Affording the Veteran the benefit of the doubt, the Board finds that the aforementioned evidence demonstrates occupational and social impairment with deficiencies in most areas throughout the appeal period. Prior to November 2013, the evidence shows that the Veteran's PTSD has been manifested by emotional and social withdrawal, irritability, sleep disturbances, suicidal thoughts, depression, and interpersonal difficulties, particularly in regard to his prior marriages and with his adult child. Such symptomatology is consistent with a higher 70 percent rating. Accordingly, the Board finds that a 70 percent rating is warranted throughout the appeal period. However, examinations and treatment records do not indicate that the Veteran's symptoms rise to the severity, frequency, and duration required of a 100 percent rating. For example, at no point in the claims file was evidence found of persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation or own name, nor was evidence of a similar type and degree of such symptoms found. Rather, the Veteran consistently appeared appropriately groomed, capable of maintaining effective relationships with his wife and some family members, and participating in church. Thus, affording the Veteran the benefit of the doubt, a 70 percent rating, but no higher, is warranted. The Board further notes that the GAF scores assigned support such a determination. The Veteran was assigned GAF scores of 55-60 and 48, which contemplate moderate to severe symptomatology. Overall, the disability picture presented by GAF scores reflect the moderate to severe symptomatology contemplated by a 70 percent rating. See DSM-IV (GAF score ranging from 41 to 50 reflects severe symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job), while a GAF score ranging from 51 to 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-worker)). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 370-71 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record)." Accordingly, the Board finds that a 70 percent, but no higher, rating for PTSD is warranted for the entire appeal period prior to and from November 12, 2013. III. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran is service-connected for PTSD (now rated as 70 percent disabling), spondylolisthesis of the lumbar spine (rated as 60 percent disabling from December 16, 2010), radiculopathy of the left lower extremity (rated as 20 percent disabling from December 16, 2010), limitation of motion of the left index finger (rated as 10 percent disabling), limitation of motion of the left long finger due to shell fragment wound (rated as 10 percent disabling), tinnitus (rated as 10 percent disabling), radiculopathy of the right lower extremity (rated as 10 percent disabling from December 16, 2010), and hearing loss, limitation of motion of the left thumb, limitation of motion of the left little finger, and left upper extremity scars, each rated as noncompensable. His combined rating was 80 percent from September 3, 2009, and 100 percent from December 16, 2010. The Veteran's treatment records and Social Security Administration records reflect that he last worked in December 2008 in carpentry/construction as a supervisor. Thus, the Veteran has not been employed at any point relevant to the appeal period. In addition to the above-discussed medical evidence, the claims file also includes a January 2013 VA TDIU examination in which the Veteran reported that he had difficulty completing necessary reports due to loss of left hand function. In addition, he could not stand or walk for long periods without significant pain in his lumbar spine and numbness down his left leg. He tried working a job at Home Depot for one day in 2012 providing estimates, but could not complete the reports due to his hand and walking limitations. He did not finish the day and had not worked since. The examiner noted that, due to the Veteran's back condition, employment that required him to lift or squat, walk long distances, stand for long periods, or sit for long periods would be limited. As noted above, the 2013 and 2017 VA examiners specifically indicated that the Veteran was unable to secure or maintain gainful employment due to his service-connected PTSD. In regard to the period prior to December 16, 2010, the Board acknowledges that the assessments of the severity of the Veteran's psychiatric symptom have varied, and these examiner's observations occurred after December 2010. However, given the Board's discussion above noting the consistency of the Veteran's symptoms, the Board resolves reasonable doubt in the Veteran's favor and finds that the Veteran was unemployable due to his PTSD prior to December 16, 2010. With respect to the period from December 16, 2010, as indicated above, the receipt of a 100 percent schedular disability evaluation for a service-connected disability or disabilities does not necessarily moot the issue of entitlement to a TDIU. Bradley, 22 Vet. App. at 293-94. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, Bradley recognized that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation under 38 U.S.C.A. § 1114(s). Bradley, 22 Vet. App. at 293-94. However, Bradley also explains that a 100 percent combined evaluation does not qualify as "a service-connected disability rated as total" under the statute. 38 U.S.C.A. § 1114(s); Bradley, 22 Vet. App. at 290. Here, the Board has considered whether a single service-connected disability, alone, can provide a basis for award of a TDIU. Again, the 2013 and 2017 VA examiners specifically indicated that the Veteran was unable to secure or maintain gainful employment due to his service-connected PTSD. Accordingly, the Board finds that the Veteran is unemployable due to his service-connected PTSD, alone, and that a TDIU is warranted for the entire appeal period. ORDER Entitlement to service connection for COPD, to include as due to asbestos exposure, is denied. An initial, 70 percent rating for PTSD, prior to November 12, 2013 is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a rating in excess of 70 percent for PTSD, from November 12, 2013, is denied. Entitlement to a TDIU is granted, subject to the controlling regulations applicable to the payment of monetary benefits. REMAND Unfortunately the Board finds that further AOJ action on the claim on appeal is warranted, even though such will, regrettably, further delay an appellate decision on the matter on appeal. The Veteran contends that his left hand symptoms stem from an in-service shell fragment wound, leading to his current symptoms of numbness and decreased grip in the left hand. The Board notes that the Veteran is service-connected for limitation of motion of the left thumb, left index finger, left long finger, and scars related to the shell fragment wound. The Veteran's service treatment records reflect the Veteran was seen in July 1967 for a smashed left hand. He had swelling and tenderness of the fourth and fifth metacarpal and an abrasion over the dorsum. In August 1967, he was treated for shrapnel injury of the left hand. On discharge examination in March 1968, while shrapnel wound of the left hand was indicated, no other abnormalities with respect to the left upper extremity were noted. Following service, on VA examination in November 2009, the Veteran reported that he sustained a shell fragment wound while stationed in Vietnam. He had a through and through injury to the first dorsal interosseous muscle, with no nerve or artery involvement. He also suffered a shell fragment injury to the dorsal aspect of his proximal right forearm from the same rocket. He currently reported numbness in his left hand and arm, with diminished grip strength. He had a diagnosis of left cubital and left carpal tunnel syndrome. After physical examination, the examiner diagnosed shell fragment wound to the proximal left forearm and though the first dorsal web space of his left hand. The examiner indicated that the current condition of numbness in his hand and arm with diminished grip strength was due to cubital tunnel and carpal tunnel syndrome, and has nothing to do with the injuries from the wounds he sustained while in Vietnam. The examiner noted that the Veteran's shrapnel wound and left carpal/cubital tunnel syndrome were separate entities. A January 2010 VA physical medicine rehabilitation consult reflects that the Veteran was referred for electrodiagnostic evaluation for left hand numbness. He reported a greater than 10 year history of left hand numbness, mainly involving the first-third digits, associated with lost hand dexterity and hand weakness, causing object dropping. He reported that he was diagnosed with carpal tunnel syndrome 10 years prior at the Cleveland Clinic. An EMG study was limited due to failure to complete the test. Severe left median sensorimotor mononeuropathy was indicated. On VA examination in January 2013, the examiner diagnosed left hand shrapnel wound muscle injury. The examiner indicated that there were no medical records establishing chronic problems with the Veteran's left hand numbness and his left hand shrapnel wound. An x-ray in November 2011 did not show any shrapnel debris. The Veteran reported only a 10 year history of left hand numbness and pain. The Veteran pain and numbness with loss of function is more than not related to his severe carpal tunnel syndrome and not the left hand shrapnel wound. In an addendum opinion, the examiner opined that the claimed carpal tunnel/cubital tunnel syndrome are less likely as not proximally due to or a result of the Veteran's service-connected condition. In so finding, the examiner noted that carpal tunnel and cubital tunnel syndromes are caused by external pressure on the nerve in these locations. There was no evidence of shrapnel fragments causing this condition. The Board finds these opinions inadequate, as they fail to provide a complete opinion as to whether the claimed disability had its onset in or is otherwise related to service. In addition, the January 2013 VA examiner appears to provide an opinion on secondary service connection, but fails to address whether the claimed disability is aggravated by a service-connected disability. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Moreover, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). For the foregoing reasons, the Board concludes that these examinations are inadequate, and remand for additional examination and opinion on this matter is warranted. Accordingly, the case is REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder updated treatment records, including any records of VA treatment. 2. The AOJ should also refer the electronic claims file to an appropriate medical professional for examination and opinion pertaining to the claimed left carpal/cubital tunnel syndrome. The entire claims file must be made available to the designated examiner. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left carpal/cubital tunnel syndrome (1) had its onset in service or is otherwise medically related to service, to include the shrapnel wound sustained therein; or (2) were caused by or aggravated (permanently increased in severity beyond the natural progress of the condition) by a service connected disability, to specifically include the limitation of motion of fingers and scarring of the left hand due to shell fragment wound. If aggravation is found, the examiner should identify the baseline level of severity of the nonservice-connected disability to the extent possible. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 3. After completing all indicated development, and any additional development deemed warranted, the AOJ should readjudicate the remaining claim on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. 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. §§ 5109B, 7112 (2012). ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs