Citation Nr: 1756562 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 14-03 579 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to July 27, 2016, and in excess of 70 percent thereafter for posttraumatic stress disorder (PTSD) with depression, not otherwise specified. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to July 27, 2016. [The Veteran's claim of entitlement to service connection for a traumatic brain injury (TBI) is the subject of a separate Board decision.] REPRESENTATION Veteran represented by: Kenneth M. Carpenter, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kate Sosna, Associate Counsel INTRODUCTION The Veteran had active duty service from December 1967 to September 1969. He is the recipient of numerous awards and decorations, including the Combat Action Ribbon and the Purple Heart Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2011 by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2014, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A hearing transcript is associated with the record on appeal. In July 2015, the Board remanded the case for additional development and it now returns for further appellate review. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, to include in family relations, as a result of psychiatric symptomatology, to include suicidal ideation, depressed mood, and difficulty adapting to stressful circumstances, including work or a work like setting; however, the frequency, duration, and severity of such symptomatology have not produced more severe manifestations that more nearly approximate total occupational and social impairment. 2. The Veteran was gainfully employed until December 20, 2012; his employment thereafter was marginal. 3. Resolving all reasonable doubt in the Veteran's favor, as of December 20, 2012, but no earlier, his service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for an initial 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. As of December 20, 2012, but no earlier, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Further, neither the Veteran nor his representative has alleged any deficiency with respect to VA's duties to notify or assist. See Scott, supra (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Increased Rating Claim 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. § 1155; 38 C.F.R., Part 4. 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. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation 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. Separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran contends that a higher rating for his PTSD is warranted due to the severity of his symptoms, to include avoidance, isolation, nightmares, flashbacks, anxiety, hypervigilance, depression, impaired sleep, obsessive scheduling, tearfulness, survivor's guilt, memory problems, cognitive impairment, and concentration problems. Such disability was evaluated as 30 percent disabling as of August 30, 2010, the date of service connection, and as 70 percent disabling as of July 27, 2016, under the criteria of DC 9411, which provides ratings under the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under DC 9411, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV)). Pertinent to this appeal, a GAF score of 51 to 60 indicates 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-workers). Scores ranging from 41 to 50 reflect serious 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 the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Parenthetically, the Board notes that the revised DSM-5, which, among other things, eliminates GAF scores, applies to appeals certified to the Board after August 4, 2014, which is not the case here. See 79 Fed. Reg. 45, 093 (Aug, 4, 2014). Based on the evidence of record, the Board finds that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas since his August 2010 date of service connection, thus warranting a 70 percent rating for the entirety of the appeal period. Specifically, the evidence indicates that the Veteran's PTSD symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Regarding the Veteran's social functioning, he maintained a marriage for many decades. That said, VA treatment records indicate that both the Veteran and his spouse filed for divorce on several occasions during the appeal period, but ultimately stayed together for insurance benefits and convenience to their children. Indeed, the Veteran regularly reported feeling indifferent towards or emotionally distant from his wife, noted minimal interaction with her at the November 2010 VA examination, and a complicated marriage at the August 2016 examination. Aside from his wife and immediate family (children), the Veteran denied having numerous friendships or social activities aside from speaking to other veterans about the circumstances of their service and maintaining contact over the phone with a friend from high school. See November 2010, August 2015, and August 2016 VA examination reports and March 2014 hearing transcript. While the Veteran kept busy with several hobbies during the appeal period, including fishing, exercise, gardening, reading, and playing the guitar, it was specifically noted by the November 2010 VA examiner that all of these activities were conducted in solitary environment. Turning to occupational impairment, the evidence of record indicates that the Veteran retired in December 2012, although he continued to work occasionally thereafter to maintain insurance benefits for his wife who was diagnosed with cancer during the appeal period. However, the November 2010 VA examiner found the Veteran experienced intense distress, difficulty expressing affection, problems sleeping, and problems relaxing, making it reasonable to believe his PTSD symptoms would have interfered with his employment. Thereafter, in August 2015, a VA examiner opined the Veteran's symptoms had been relatively stable since 2010 and that the Veteran could work in a job which had minimal or mild levels of social interaction and one which was not subject to frequent lay-offs (as this caused the Veteran intense stress). The Board observes that, during the appeal period, the Veteran's PTSD symptoms included irritability, exaggerated startle response, avoidance, isolation, depression, tearfulness, impaired sleep, hypervigilance, suicidal ideation, and anxiety and, consequently, it is not reasonable to assume that these symptoms would not markedly interfere with employment, even in a position that did not involve significant interaction with others. Further, while acknowledging that VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected psychiatric disability, the United States Court of Appeals for Veterans Claims (Court) recently indicated that suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (the language of the regulation indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas). Here, the Veteran endorsed suicidal ideation during the November 2010 VA examination. While he routinely denied suicidal ideation on direct questioning while receiving treatment, the available records indicate the Veteran was nevertheless questioning his existence. For instance, in January 2010, he reported passing thoughts of death and not wanting to wake up. Then, in November 2013, the Veteran speculated as to the meaning of life. At the March 2014 Board hearing, the Veteran reported he would rather have stayed in Vietnam than return home. More recently, in February 2015, the Veteran relayed to a treatment provider that he wished he had not returned from deployment and that he felt overwhelmed and needed a break. In June 2015, the Veteran relayed that his deceased comrades are likely more at peace than he is. In addition to the foregoing, the Veteran and his wife have provided affidavits in which they both attest to his suicidal ideation throughout the appeal period. Thus, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a 70 percent rating for PTSD have been for the entire appeal period. Nevertheless, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met at any point during the appeal period. In this regard, the evidence does not show that the Veteran had total social and occupational impairment due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Indeed, the record reflects that, despite some symptomatology associated with a 100 percent rating (including problems remembering names of close friends) during the appeal period, he had some form of relationship with his wife, and his children lived in close proximity to him (see 2011 and 2015 VA examination reports). As such, he was not completely isolated or totally socially impaired. Ultimately, the most probative evidence of record indicates the Veteran's symptoms did not result in total social and occupational impairment. During the course of the appeal, including at the March 2014 hearing, the Veteran repeatedly referenced problems with his memory, concentration, and cognitive abilities, which he associated with a past TBI. However, the most probative evidence of record does not support a finding that the Veteran suffers from residuals from a TBI. See April 2010, June 2010, July 2010, and October 2014 neurology notes; and September 2010 August 2015, September 2015, and November 2015 VA examinations; but see January 2015 letter from the Veteran's nurse practitioner and August 2016 contract examination report. Instead, treating clinicians, including neurologists, psychologists, and other medical professionals, have routinely attributed the Veteran's cognitive difficulties (including problems concentrating, comprehending, remembering, and organizing his thoughts) to his service-connected PTSD. Thus, all of the Veteran's psychological and cognitive symptoms have been contemplated in the 70 percent PTSD rating assigned herein. Mittleider v. West, 11 Vet. App. 181 (1998). The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating schedule, including feelings of guilt and extreme rigidness in daily activities. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula, as they are not of such a duration, severity, or frequency to result in total occupational and social impairment. Ultimately, the Board finds that the Veteran's PTSD does not warrant a rating in excess of 70 percent. It is important to note that the VA examiners found that, prior to July 27, 2016, the Veteran's PTSD symptoms were commensurate with lower ratings. However, the record also indicates that the Veteran is a stoic and private person who has difficulty opening up regarding his symptomatology. For instance, the November 2010 VA examiner stated the Veteran "...may be an individual who does not like to complain and therefore has a hard time acknowledging and reporting problems or 'shortcomings'." Thereafter, a December 2013 examiner noted the Veteran persistently avoided dealing with things and exhibited emotional deflection. Then, in January 2014, a VA clinician noted the Veteran was uncomfortable with emotion and, in January 2015, he was noted to exhibit extreme avoidance. Overall, it is clear to the Board that the severity of the Veteran's symptoms is not always reflected in the available treatment records given his difficulty in discussing them. Nevertheless, there is no indication in either the lay or medical evidence that the Veteran was concealing symptoms reflective of a 100 percent rating. Indeed, such would be difficult to do, given the severe and identifiable nature of such symptoms, such as the presence of delusions, hallucinations, and inability to remember one's own name. In assessing the severity of the disability under consideration, the Board has considered the Veteran and his wife's assertions as to the type and frequency and/or severity of his symptoms, which they are certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994). Additionally, the Board notes that the lay reports are credible as to the Veteran's symptomatology, as they have been consistent with his reports to treatment providers, and his statements were not challenged by his treatment providers. However, the criteria needed to support a higher rating, requires medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of a higher 100 percent rating for PTSD. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that the Veteran's symptomatology referable to his PTSD has been stable throughout the period on appeal. Therefore, assigning staged ratings for his PTSD is not warranted. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. Doucette v. Shulkin, 28 Vet. App. 366 (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). Ultimately, the Board finds that a 70 percent rating, but no higher, for PTSD is warranted for the entire appeal period; however, the preponderance of the evidence is against a rating in excess of 70 percent. Therefore, the benefit of the doubt doctrine is not applicable except as has been applied to the rating assigned herein, and the Veteran's claim for a higher initial rating is otherwise denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. III. Entitlement to a TDIU prior to July 27, 2016 The Veteran asserts that he is unable to secure or maintain substantially gainful employment due to his service-connected disabilities. Specifically, at the March 2014 Board hearing, he intimated that he left the workforce because employers expected more of him than he was able to do. Additionally, in an April 2017 affidavit, the Veteran acknowledged having conflicts with his co-workers about the United States' involvement in Iraq and that his hypervigilance and impaired sleep impacted his ability to work. Initially, the Board notes that the Veteran has never filed an independent claim for a TDIU. Instead, the issue of entitlement to a TDIU has been raised in association with his claim for a higher initial rating for his service-connected PTSD pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). When a veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned when the disabled person is unable to secure or follow a substantially gainful occupation. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); Pratt v. Derwinski, 3 Vet. App. 269, 272 (1992); Floore v. Shinseki, 26 Vet. App. 376, 383 (2013). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice, supra. Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor). By virtue of this decision, since August 30, 2010, the Veteran has been service-connected for bilateral hearing loss (rated as 10 percent disabling from August 30, 2010, to January 21, 2014; 30 percent disabling from January 22, 2014, to May 26, 2014; 20 percent disabling from May 27, 2014, to May 27, 2015; 40 percent disabling from May 28, 2015, to August 22, 2016; and 20 percent disabling thereafter); tinnitus (rated as 10 percent disabling); and PTSD (rated as 70 percent disabling). As the Veteran has had one disability rated as 60 percent disabling (PTSD), he meets the schedular threshold criteria for consideration of a TDIU for the entire appeal period. 38 C.F.R. §§ 4.25, 4.16(a). Additionally, upon review of the evidence, the Board finds that the Veteran's service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation since December 20, 2012, which is the day he stopped working in a substantially gainful manner. Turning to his educational and work experience, the evidence of record indicates that the Veteran has a high school diploma and subsequently worked as a carpet and flooring installer. See June 2016 Application for Increased Compensation Based on Unemployability and November 2010, August 2015, and August 2016 VA examination reports. He credibly reported in August 2012 that his PTSD symptoms, including poor concentration, memory problems, and cognitive deficits, interfered with his employment as he was unable to figure angles or calculate without extreme confusion and head pain. This statement is supported by a September 2016 submission from an employer he tried to work for in 2013. Specifically, the senior project manager noted the Veteran only worked for the company for one week and was let go due to memory loss, the inability to manage fellow workers, confusion, stress, and the general inability to perform simple work-related tasks. During his August 2015 VA psychiatric examination, the Veteran noted that he retired when work became too stressful with his psychiatric disorder. The examiner noted there was no objective indication his PTSD symptoms necessitated his retirement, but the aforementioned information from his previous employer that was submitted after the examination does in fact bolster the Veteran's subjective reports. In any event, the examiner opined the Veteran could work in a position with minimal or mild social interaction with limited stress regarding the likelihood of being retained. Here, the Board notes that, given the nature of carpet and flooring installation and the heavy products and equipment used therein, it is unlikely the Veteran's experience would allow for isolated work. Later, at an August 2016 VA examination, the examiner noted the Veteran experienced difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including at work. In addition to the psychiatric examination reports of record, VA examiners also opined that the Veteran's bilateral hearing loss and tinnitus would impair his ability to work due to his difficulty understanding what others said and impaired sleep caused by his tinnitus. See May 2014, September 2015, and August 2016 VA examination reports. The record also contains a June 2017 vocational assessment from Ms. C.E., who holds a master's degree in rehabilitative counseling. After performing a comprehensive review of the Veteran's records, Ms. C.E. opined that the Veteran would be unable to perform the basic requirements for unskilled, entry-level work, to include sustaining focus, due to his PTSD symptoms. In this regard, she estimated that the Veteran's symptoms would cause increased absenteeism and reduced productivity. While her opinion is largely speculative in nature, the Board still affords it some probative weight given her training and expertise in the employment field. Notably, there is no indication that the Veteran possesses any computer training and he has never held a position in an office setting; to the contrary, the evidence indicates he has worked exclusively as a manual laborer. The question of employability is ultimately a legal one, not a medical one. The evidence, as described and discussed above, clearly shows that the Veteran is not able to maintain the type of employment he is experienced in due solely to his service-connected disabilities. In this regard, the Board finds the opinion of the above medical professionals to be highly probative as they considered the full evidence of record, including lay statements, and clearly articulated how the Veteran's service-connected disabilities would hinder employment. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Therefore, based on the analysis above and resolving all doubt in the Veteran's favor, the Board finds that his service-connected disabilities prevented him from securing or following substantially gainful employment since December 20, 2012. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, Gilbert, supra. While the record indicates the Veteran held employment sporadically thereafter, there is no indication that such employment was substantially gainful. To the contrary, it appears the Veteran worked, at most, for several weeks a year to maintain his health insurance. The Board finds this employment to be marginal. Finally, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra; see also Akles v. Derwinski, 1 Vet. App. 118 (1991). ORDER An initial 70 percent rating, but no higher, for PTSD is granted, subject to the laws and regulations governing the payment of monetary awards. As of December 20, 2012, but no earlier, a TDIU is granted, subject to the laws and regulations governing the payment of monetary awards. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs