Citation Nr: 18143779 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 16-14 716 DATE: October 22, 2018 REMANDED Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1983 to June 2003. This matter comes to the Board of Veterans’ Appeals (Board) from a February 2014 rating decision, which in pertinent part, denied entitlement to TDIU. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. The Veteran contends that he is entitled to TDIU. Evidence indicates that there may be outstanding relevant VA treatment records. VA treatment records reflect that in early 2013, the Veteran moved to Florida. However, treatment records from the Orlando VAMC do not begin until January 2014. Furthermore, these treatment records indicate that the Veteran was being followed by VA psychiatry for his PTSD, but VA psychiatry treatment records are not associated with the Veteran’s electronic claims file. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. A remand is required to allow VA to obtain them. Evidence indicates that the Veteran is in receipt of vocational rehabilitation and employment (VRE) services. However, the Veterans’ VRE records have not been associated with his electronic claims file. Evidence indicates that there may be relevant outstanding Social Security Administration (SSA) records. SSA records were obtained in January 2014. However, the Veteran has submitted documentation that he appealed the denial of SSA benefits and was granted benefits in January 2016. A remand is required to allow VA to obtain SSA records since January 2014. Finally, the Veteran was afforded a VA PTSD examination in February 2014. The examiner found that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. While the examiner indicated that the Veteran was not working at the time as his double hip replacement was pending, he did not describe the impact of the Veteran’s PTSD on his employment. The Board finds the February 2014 VA PTSD examination inadequate. As the Veteran meets the percentage requirements for schedular TDIU, the effects of the Veteran’s service-connected PTSD on ability to perform acts required for gainful employment should be addressed. Furthermore, no VA examination has addressed the combined effects of the Veteran’s service-connected disabilities on employment. Therefore, upon remand, the AOJ should obtain a new VA examination and medical opinion addressing the individual and combined functional effects of the Veteran’s service-connected disabilities on his ability to perform acts required for gainful employment. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records from the Orlando VAMC for the period from January 2013 to January 2014, and any psychiatric treatment records from January 2013. 2. Obtain the Veteran’s VRE file. 3. Obtain the Veteran’s Social Security Administration records since January 2014. Document all requests for information as well as all responses in the claims file. 4. Schedule the Veteran for an examination[s] by an appropriate clinician[s] to provide comments as to the individual and combined functional effects of the Veteran’s service-connected disabilities. The Veteran is service-connected for PTSD, splenectomy, bilateral shoulder, bilateral knee, left hand, tinnitus, headache, thoracic spine, and right ankle disabilities. The examiner should elicit from the Veteran his complete educational, vocational, and employment history and should note his complaints regarding the impact of his service-connected disabilities on employment. The examiner should fully describe the functional effects of each disability under consideration on his activities of daily living, to include employment. If no service-connected disability, alone, is deemed to functionally preclude employment, the clinician must consider and describe the combined functional effects of the service-connected disabilities on his ability to perform the mental and physical actions required for gainful employment. In addressing the above, the clinician should consider all medical and lay evidence, to include private and VA treatment records, VA examination reports, vocational rehabilitation and employment reports, and lay statements. The physician should describe what types of employment activities would be limited because of the service-connected disabilities, what types of employment would not be limited (if any), and whether any limitation on employment is likely to be permanent. 5. After completing the above, and any other development as may be indicated, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Owen, Associate Counsel