Citation Nr: 1801658 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 13-28 641 DATE THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) and anxiety disorder, based upon substitution of the appellant as the claimant. 2. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU), based upon substitution of the appellant as the claimant. ORDER Entitlement to an initial evaluation in excess of 30 percent for PTSD and anxiety disorder based upon substitution of the appellant as the claimant is denied. Entitlement to a TDIU based upon substitution of the appellant as the claimant is denied. FINDINGS OF FACT 1. Throughout the appellate period until the Veteran's death, the Veteran's symptoms of PTSD and anxiety disorder were manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. The Veteran's service connected disabilities had not rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent disabling for PTSD and anxiety disorder based upon substitution of the appellant as the claimant have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2017). 2. The criteria for a TDIU based upon substitution of the appellant as the claimant have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty from May 1968 to November 1969. The Veteran died in June 2010, and the appellant is his surviving spouse. The appellant has been substituted as the claimant for the purposes of the issues on appeal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office in Houston, Texas (RO), granting service connection for PTSD and anxiety disorder evaluated as 30 percent disabling effective February 27, 2009. Because the RO certified the issue of TDIU and the undersigned heard testimony on it without the Veteran having appealed it, pursuant to Percy, the Board takes jurisdiction of the issue, which the RO denied in a May 2010 rating decision. Percy v. Shinseki, 23 Vet. App. 37, 45-47 (2009), In September 2017, the appellant and the Veteran's son testified at a videoconference hearing before the undersigned, and a transcript is of record. This appeal was processed using the Virtual VA (VVA) and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future review of this appellant's case should take into consideration the existence of these electronic records. Veterans Claims Assistance Act of 2000 As required by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159(b) (2017). The appellant has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (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 appellant fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). As such, the Board will now review the merits of the appellant's claims. Law and Analysis The appellant contends that the Veteran's overall disability picture regarding PTSD and anxiety disorder was more disabling than the assigned initial evaluation of 30 percent. In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran's symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Disability evaluations are determined by assessing the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2 (2017). If there is a question as to which evaluation should be applied to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran's disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The nomenclature used in the rating schedule for mental disorders is based upon the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 38 C.F.R. § 4.130 (2017). Although certain symptoms must be present in order to establish the diagnosis of PTSD, it is not the symptoms but their effects that determines the level of impairment. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002) (quoting 61 Fed. Reg. 52,695, 52,697 (Oct. 8, 1996)). "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." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). When rating a mental disorder, VA 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. The rating agency must assign a rating 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) (2017). While the extent of social impairment must be considered, an evaluation shall not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2017). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a global assessment of functioning (GAF) score, is to be considered, but it is not determinative of the percentage disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126 (2017); VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). GAF scores correlate to a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (quoting American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 32 (4th ed. 1994)). Under the DSM-IV, a GAF score of 31 to 40 reveals some impairment in reality testing or communications (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score between 41 and 50 indicates that a veteran has 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). A score of 51-60 is appropriate where there are 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). A score of 61-70 indicates mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Here, the Veteran's disability was evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017), for which in pertinent part the General Rating Formula for Mental Disorders delineates: A 30 percent rating is warranted when there is occupational and social impairment with occasional decreases 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, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals that 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 worklike setting); inability to establish and maintain effective relationships. Id. The maximum rating of 100 percent requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. The Board observes 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130 were updated via an interim final rule, made immediately effective August 4, 2014, in part to substitute references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The Secretary directed that the changes be applied to applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, but not to claims certified to or pending before the Board, the United States Court of Appeals for Veterans Claims (Court), or the United States Court of Appeals for the Federal Circuit. 79 Fed. Reg. 45, 093, 45,094-096 (Aug. 4, 2014); Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). Since the Veteran's claim was certified to the Board in January 2016, the DSM-5 applies. Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is 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 the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the appellant's claims. In August 2009, the Veteran was afforded a VA examination for PTSD. It was noted that the Veteran had a high school education. The Veteran reported that he was depressed, had suicidal thoughts, and nightmares. Because he lived in the woods, he had no social interaction. Specific to his PTSD symptoms, the Veteran reported that he was irritable; had angry outbursts; could be violent; irritability; violent temper; and trouble sleeping, described as waking up frequently and having nightmares. The Veteran reported that his symptoms were constant and they affected his total daily functioning. The Veteran reported that because of health issues he had been fired from his job, and since then, he had more trouble with his PTSD symptoms. The Veteran also reported depression and anxiety, with the following symptoms: being sad all the time; feeling hopeless; not getting pleasure from things; feeling guilty and being punished; feeling disappointed in himself and worthless; crying and having suicidal thoughts without plan for carrying them out; not being interested in anything; trouble making decisions; lacking energy and having reduced appetite; feeling scared and at times terrified; and being afraid of dying. The Veteran reported that his symptoms were constant and that they affected his total daily functioning in that he was withdrawn and not doing anything. It was noted that the Veteran was prescribed 20 mg Citalopram with good response and no side effects. He had not received psychotherapy within the last year. He had not had any psychiatric hospitalizations or emergency room visits related to psychiatric problems. The Veteran reported that he had worked for the same employer for 30 years, and the relationships with his supervisor and co-workers were fair. He reported working at a couple of other jobs for a year each and that the relationships with supervisors and co-workers were good. The Veteran reported that his relationship with his sister was fair. He reported that his relationship with his wife of 37 years was fair, that he was somewhat distant. He reported the relationship with his three children as good. The Veteran reported having recollections, including flashbacks, of the in-service stressful events. He reported having a recurring, distressing dream about the event, waking up all sweaty and not able to go back to sleep. He reported that he jumps and rolls out of bed , or hits the ground if he hears shooting. He reported avoiding stimuli such as reading or watching film about the war. He reported staying to himself even at work; not socializing or going to church; not going to parties; and eventually people stopped coming around. It was noted that the Veteran had a persistent restricted range of affect, which had caused the Veteran to distance himself from others. The Veteran reported persistent difficulty concentrating, his mind bouncing from one thing to another. The Veteran reported hyperarousal and hypervigilance, sitting against the wall where he can see the door in restaurants. It was noted that the Veteran's appearance, hygiene, and behavior were appropriate. It was noted that the Veteran displayed a near-continuous depressed affect. Communication, speech, and concentration were noted as within normal limits. It was noted that panic attacks were present and occurred more than once per week. It was noted that there was no history of delusions or hallucinations. It was also noted that obsessional rituals were present that were severe enough to interfere with routine activities. It was observed that the Veteran's memory was mildly impaired with forgetting names, directions, recent events. Suicidal ideation was reported as present, having thoughts but not a plan. The Veteran was diagnosed as having PTSD and anxiety disorder NOS, with the PTSD symptoms having gotten worse since his diagnosis of cancer and being fired. The examiner assigned a GAF score of 45. The examiner opined that the best description of the Veteran's psychiatric impairment from his symptoms was occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally his was functioning satisfactorily with routine behavior, self-care, and normal conversation. It was opined that the Veteran needed to seek follow-up treatment for counseling. The Veteran's VA medical records show that he received psychiatric services for treatment of PTSD and major depressive disorder from November 2009 to April 2010, which included medication. The record of the initial evaluation in November 2009 shows that since December 2008 the Veteran had been diagnosed with pancreatic cancer, treated with a Whipple procedure in January 2009, which was followed by radiation, and chemotherapy. At the time of the evaluation, the Veteran reported that he had an inoperable hernia, was frequently treated for ascites, and that he was in much pain. The Veteran reported that prior to the Whipple procedure he worked very long hours, usually seven days a week, and rarely took time off. He reported that since his surgery he was quite physically disabled. The Veteran reported that he used work as therapy. The Veteran reported his symptoms consistently as stated during the August 2008 VA examination. The Veteran reported waking one or two times per week due to panic attacks. He reported panic symptoms of tachycardia, sweating, trembling, and dyspnea. The Veteran reported lots of fatigue as well as poor motivation, appetite, and concentration. The Veteran denied suicidal ideation. It was noted that the Veteran denied manic symptoms. It was noted that thought process was clear and goal directed. The Veteran's medications were adjusted. The Veteran was assigned a GAF score of 48. The note for December 2009 reveals that the Veteran had benefit from the changes in medications but reported that once a week he would wake up drenched in sweat. He denied any suicidal ideations. It was noted that the Veteran was well-groomed with good hygiene; and cognition, judgment, and insight were grossly intact. It was noted that he was recovering from hernia repair surgery. In January 2010, it was noted that the Veteran had been diagnosed as having a new metastasis on his liver, and there were plans for him to start chemotherapy. The Veteran reported having nightmares several times a week, and denied suicidal ideation. The Veteran was assigned a GAF score of 48. In February 2010, the Veteran reported that his PTSD symptoms were getting worse, particularly intrusive memories during the day. It was discussed how the Veteran had used work and activity to distract himself over the years. The Veteran denied suicidal ideation. In March 2010, the Veteran discussed his survivor's remorse. It was observed that attempts to explore his feelings about this were met with passive resistance and avoidance. The end of the session was spent discussing how poorly he felt due to chemotherapy. The Veteran reported no suicidal ideation. In March 2010, the Veteran was assigned a GAF score of 48. During the Veteran's last session in April 2010, he was assigned a GAF score of 48. It was reported that chemotherapy had been discontinued and that the Veteran did not have any other treatment options. He was continued on his psychiatric medications. In an August 2013 statement, the appellant disagreed with the 30 percent disability evaluation for PTSD. The appellant stated that she and the Veteran met in 1970, shortly after he returned from Vietnam. She stated that the Veteran had always been very distant from her, their children, and friends. The Veteran was either working or out in his shop. She stated that even at work, the Veteran isolated himself, his co-workers left him alone and his boss tolerated it because the Veteran was a good worker and "could do any job they put him on." She stated that all the Veteran wanted to do was work to keep his mind occupied and his body so tired that he could sleep; most nights he fell asleep on the couch or in the tub because he was so tired. She stated that if he heard a noise when asleep, he would dive from bed and hit the floor. She stated that the Veteran generally stayed expressionless, gave short answers, would go off by himself, ignored everyone, and was unable to have a close social relationship with anyone. She stated that she raised their children on her own because the Veteran did not engage with them; usually he would leave the house and hide away in his shop. In an October 2015 statement, the appellant reiterated these sentiments. In September 2017, the appellant testified at a videoconference hearing. She testified that she had known the Veteran since 1970. She testified that the Veteran had unprovoked angry outbursts at work, that he would snap at a moment's notice. She stated that those at work and the family knew to just leave the Veteran alone. She stated that the Veteran wanted to stay at work, he would work 24 hours a day if he could. She stated that he even worked while having pneumonia. She affirmed that the Veteran used work to mask his PTSD symptoms and that his symptoms became worse when he was not able to work any longer due to diabetes. She testified that after the Veteran had surgery for pancreatic cancer, he refused to take the prescribed pain medication because of the nightmares. The appellant testified that the Veteran could not open up with anyone and did not like the idleness of socializing. She recounted visiting with the Veteran's sister and that the Veteran would sit on the couch like a lump of clay; but if she needed a washer fixed, he was happy, up and doing it. She stated that the Veteran did not have any hobbies and did not go to church. The extent of his hobbies was figuring out how to fix things by himself and cutting down trees. She also testified that they always lived in the woods, but there was a honkytonk nearby. Periodically there would be gunfights and they would hear gunshots. She testified that the Veteran would jump out of bed and hit the floor, and he would have nightmares at night. The appellant testified that the Veteran's diabetes caused him to slow down such that working became problematic. The Veteran's son testified that he jumped at the offer of working four ten-hour days. It was stated that the Veteran's job was very physical in that he fixed all the equipment at a wood plant, replacing motors, bearings, and welding up cracks. It was stated that toward the end, the employer had the Veteran staying in the shop more, rebuilding smaller things, instead of going out on the floor and working hard. It was stated that this was the only type of work the Veteran had ever done. The Veteran's son testified that even after the Veteran was no longer employed, he continued to do the same type work at home. Any time someone mentioned they needed something fixed, the Veteran would drop what he was doing and kept himself busy fixing things for people. It was stated that the Veteran would not let anyone pay him because it was something he did to occupy his mind. The Board finds the Veteran's, appellant's, and the Veteran's son's statements competent, credible, and affords them great weight as to the Veteran's symptoms of PTSD and anxiety disorder and the effects those symptoms had on the Veteran. Competent lay evidence is any evidence that does not require "the proponent to have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person." 38 C.F.R. § 3.159(a)(2) (2017); see Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). They are not, however, competent to state whether the Veteran's symptoms warrant a specific rating under the schedule for rating disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Based upon the evidence, the Board finds that the Veteran's disability picture more nearly approximated the criteria for a 30 percent rating. The record demonstrates that the Veteran had 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. The evidence shows that the Veteran experienced depression, anxiety, panic attacks at least weekly, chronic sleep impairment, and mild memory loss. The Board finds that a rating in excess of 30 percent is not warranted since at no point during the appellate period did the Veteran demonstrate occupational and social impairment with reduced reliability and productivity. While the Veteran had a restricted range of affect and multiple panic attacks per week, his speech was normal, he did not have difficulty in understanding complex commands, and his memory was not so affected that he was unable to complete tasks. His judgment and abstract thinking were not impaired. In fact, the Veteran's thought process was clear and goal directed. The Veteran had a long-standing history with family and friends of disturbances in his mood, and he led an isolated existence, but he was able to maintain a successful employment history with the same employer for thirty years with the cooperation of others in leaving him alone. Furthermore, the Veteran did not demonstrate occupational and social impairment with deficiencies in most areas. During the August 2009 VA examination, the Veteran reported having suicidal thoughts; however, throughout the period from November 2009 to April 2010, he consistently denied having suicidal thoughts. In the August 2009 VA examination report, the examiner noted the presence of obsessional rituals, but they were no identified nor explained how they impaired the Veteran. There is no evidence that the Veteran had any psychiatric hospitalizations or emergency room visits related to psychiatric symptoms. While the evidence shows that the Veteran experienced near-continuous depression or panic, there is no evidence that it interfered with his ability to function independently, appropriately, and effectively. In fact, the Veteran maintained isolation while continuously being well-groomed with good hygiene and full-time employed. Those around him knew of his irritability and violent outbursts, and created an effective system of accommodation. Additionally, the Veteran did not demonstrate total occupational and social impairment. While the Veteran reported flashbacks and dreams, he did not report delusions or hallucinations, did not exhibit inappropriate behavior, and he was not a persistent danger of hurting himself or others. There is no evidence that he was unable to perform activities of daily living in that the evidence shows that he was always clean, appropriately dressed, and full-time employed. He was always able to communicate effectively without evidence of impairment. There is no evidence that the Veteran became disoriented to time or place, even during flashbacks, or that he forgot names of close relatives, his occupation, or his own name. The Board acknowledges that throughout the appeal period the Veteran exhibited serious symptoms, which were reflected in the consistent assignment of GAF scores of 45 and 48. Based upon the appellant's testimony and statements, the Board finds that the impairment from these symptoms, however, was mostly social impairment, not occupational. While social impairment must be considered when evaluating disability, it cannot be the sole basis for an assignment. See 38 C.F.R. § 4.126(b) (2017). Furthermore, it is not the symptoms of a disability that determine the level of impairment, rather it is their effect. See Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Here, the evidence shows that the Veteran used physical activity, i.e., paid and unpaid work, as therapy for his PTSD and anxiety symptoms at the expense of building relationships, especially with his wife and children. As a result, the Veteran successfully maintained substantially gainful employment through his employer's accommodations of his symptoms such that an evaluation in excess of 30 percent disabling is not warranted. Based upon the foregoing, as the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim must be denied. See 38 U.S.C. §§ 501, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). TDIU The appellant essentially contends that the Veteran's service connected diabetes mellitus and disabilities related to that disease rendered him unable to secure or follow a substantially gainful occupation. The Board finds that the Veteran worked in excess of full-time until he was unable to work due to the complications of non-service connected pancreatic cancer. When the schedular rating is less than total, a total disability rating for compensation may be assigned, when in the judgement of the rating agency, the claimant is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a) (2017). Such assignment may be assigned if there is only one disability ratable at 60 percent or more or if there are two or more disabilities such that at least one disability is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. The existence or degree of non-service-connected disabilities or previous unemployment status will be disregarded where the percentages for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the claimant unemployable. Id. Marginal employment shall not be considered substantially gainful employment. Id.; see Cantrell v. Shulkin, 28 Vet. App. 382 (2017). In the event the claimant is unable to secure or follow a substantially gainful occupation due to service-connected disabilities but fails to meet the percentage standards, the matter should be submitted for extra-schedular consideration by the Director, Compensation Service. 38 C.F.R. § 4.16(b) (2017). The rating board will include a full statement as to the veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b) (2017). To be granted a TDIU, the Veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). 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 v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in 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) (noting that the 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 eighth 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). In this case, the Veteran was service-connected for: diabetes mellitus, type II, with erectile dysfunction and onychomycosis evaluated as 40 percent disabling; PTSD and anxiety disorder evaluated as 30 percent disabling; tinnitus evaluated as 10 percent disabling; neuropathy, right upper extremity, associated with diabetes mellitus evaluated as 10 percent disabling; neuropathy, left upper extremity, associated with diabetes mellitus evaluated as 10 percent disabling; neuropathy, right lower extremity, associated with diabetes mellitus evaluated as 10 percent disabling; neuropathy, left lower extremity, associated with diabetes mellitus evaluated as 10 percent disabling; and noncompensable bilateral hearing loss. The Veteran's combined rating was 80 percent effective February 27, 2009; therefore, the Veteran's service-connected disabilities satisfy the schedular criteria for TDIU. See 38 C.F.R. § 4.16(a) (2017). The question for the Board, then, is whether the Veteran was able to secure or follow a substantially gainful occupation as a result of the aggregate effect of his service-connected disabilities. The Board finds that the preponderance of the competent, credible, and probative evidence of record establishes that the Veteran's service-connected disabilities had not rendered him unable to secure or follow a substantially gainful occupation. A Social Security Administration (SSA) Disability Determination and Transmittal shows that the Veteran was found disabled starting February 2008 for a primary diagnosis of pancreatic adenocarcinoma with no secondary diagnosis established. A December 2009 letter from Dr. B.R. stated that the Veteran had advanced pancreatic cancer, and because of recurrent treatment for ascites and current condition the Veteran was unable to perform any routine work. A January 2010 letter from Dr. B.R. stated that the Veteran's metastatic pancreatic cancer was terminal and that the intent of any further treatment would be palliative only. In February 2010, the Veteran's last employer indicated that the Veteran last worked in January 2009, and the last payment was made in July 2009. The reason for termination of employment was stated as due to the Veteran having exhausted the short-term disability benefit period. It was stated that the Veteran worked ten hours daily and 48 hours weekly. The Board acknowledges the appellant's experience that the Veteran's service-connected disabilities impacted his work, but the evidence of record shows that the Veteran maintained a work schedule in excess of full-time employment until he was unable to do so due to complications from pancreatic cancer. Accordingly, the Board finds that the Veteran's service-connected disabilities had not rendered him unable to secure or follow a substantially gainful occupation, and a TDIU is not warranted. Based upon the foregoing, as the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim must be denied. See 38 U.S.C. §§ 501, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In conclusion, the Board has considered the appellant's claims and decided entitlement based on the evidence. Neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to her claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). ______________________________________________ LANA K. JENG Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD Leanne M. Innet, Associate Counsel Copy mailed to: Texas Veterans Commission Department of Veterans Affairs