Citation Nr: 18143202 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-32 947 DATE: October 18, 2018 REMANDED Entitlement to a total disability rating based on individual employability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1969. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in December 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). Following the issuance of the May 2016 statement of the case, additional evidence, to include updated VA treatment records and an October 2016 VA examination pertinent to the Veteran’s posttraumatic stress disorder (PTSD), was received. The Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such evidence. However, as his claims are being remanded, the AOJ will have an opportunity to review the newly received evidence such that no prejudice results to the Veteran in the Board considering such evidence for the limited purpose of issuing a comprehensive and thorough remand. Entitlement to a TDIU. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extra-schedular consideration all cases of veterans who are unemployable due to service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). 38 C.F.R. § 4.16(b). The Veteran is service-connected for PTSD, evaluated as 70 percent disabling, effective October 4, 2016; coronary artery disease with post-surgical chest scar, evaluated as 10 percent disabling from August 31, 2010, to February 14, 2013, and 30 percent thereafter; diabetes mellitus type II with erectile dysfunction, evaluated as 20 percent disabling, effective November 9, 2010; tinnitus, evaluated as 10 percent disabling, effective November 9, 2010; hypertension, evaluated as 10 percent disabling, effective November 9, 2010; and left ear hearing loss, evaluated as noncompensable, effective November 9, 2010. The Veteran’s combined schedular rating was 10 percent, effective August 31, 2010; 40 percent, effective November 9, 2010; 60 percent, effective February 15, 2013; and 90 percent from October 4, 2016. In his March 2013 Veteran’s Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran reported that he worked full-time as a dental technician from February 2006 to August 2011, and part-time for 10 hours a week in the same capacity from August 2011 to the present. Subsequent VA treatment records reflect that he retired completely in approximately January 2016. Throughout the pendency of the appeal, the Veteran underwent multiple VA examinations that addressed the nature and severity of his service-connected disabilities and their resulting functional impairment. Upon review, the Board finds that, while each opinion adequately addresses whether each of the Veteran’s service-connected disabilities alone renders him unemployable, they do not reflect an opinion addressing the functional impact the Veteran’s service-connected disabilities, in combination, had on his employability. As a result, the Board finds remand is warranted to obtain an addendum opinion that describes the functional impact of the Veteran’s service-connected disabilities, in combination, on his ability to work, considering his education level, prior vocational training, work experience, and vocational history. In addition, the record indicates the Veteran is in receipt of benefits through the Social Security Administration (SSA). Murincsak v. Derwinski, 2 Vet. App. 363 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). Accordingly, on remand, the Veteran’s complete SSA records, including all administrative decision(s) on his application for SSA disability benefits and all underlying medical records, should be obtained on remand. Further, while on remand, the Veteran should be given an opportunity to identify any records relevant to the claim on appeal that have not been obtained. Thereafter, all identified records should be obtained, to include updated VA treatment records dated from April 2016 to the present. The matter is REMANDED for the following actions: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records dated from April 2016 to the present. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford her an opportunity to submit any copies in her possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Any determination pertinent to the Veteran’s claim for SSA benefits, as well as any medical records relied upon concerning that claim, should be obtained from SSA and associated with the record. All reasonable attempts should be made to obtain such records. If they cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A (b)(2) and 38 C.F.R. § 3.159(e). 3. Forward the record, to include a copy of this Remand, to an appropriate VA medical professional to obtain an addendum opinion regarding the functional impact of the Veteran’s service-connected disabilities, in combination, on his employability. The need for another examination is at the discretion of the examiner. Following review of the record, the examiner is requested to describe the functional impact of the Veteran’s service-connected disabilities (PTSD; coronary artery disease with post-surgical chest scar; diabetes mellitus type II with erectile dysfunction; tinnitus; hypertension; and left ear hearing loss), in combination, on his ability to work, considering his education level, prior vocational training, work experience, and vocational history. A rationale should be provided for any opinion offered. If the examiner is unable to provide an opinion without resorting to speculation, then the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, the examiner shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken with the goal so that a definite opinion can be obtained.) A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. M. Celli, Counsel