Citation Nr: 18146799 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 16-18 433 DATE: November 1, 2018 ORDER 1. New and material evidence having been received, the claim of service connection for hypertension is reopened. 2. Service connection for gout is denied. 3. Service connection for sleep apnea is denied. 4. Service connection for a disorder characterized by reduced lung capacity is denied. 5. Service connection for a right hip disorder is denied. 6. Service connection for a left hip disorder is denied. 7. Service connection for arthritis is denied. 8. A compensable rating for bilateral hearing loss is denied. 9. A rating in excess of 30 percent for coronary artery disease (CAD) is denied. 10. Since December 21, 2011, an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary awards. 11. Prior to July 31, 2013, a total disability rating based on individual unemployability (TDIU) is denied. 12. Since July 31, 2013, a TDIU is granted. REMANDED 1. Service connection for hypertension, to include as due to herbicide exposure, is remanded. FINDINGS OF FACT 1. The Veteran’s gout did not have onset during active service and is not that is causally or etiologically related to any disease, injury, or incident during service. 2. The Veteran’s sleep apnea did not have onset during active service and is not that is causally or etiologically related to any disease, injury, or incident during service. 3. The Veteran’s does not have a disorder characterized by reduced lung capacity that had its onset during active service and is not that is causally or etiologically related to any disease, injury, or incident during service. 4. The Veteran does not have a right hip disorder that had its onset during active service or within one year of discharge from service, and is not causally or etiologically related to any disease, injury, or incident during service. 5. The Veteran’s does not have a left hip disorder that had its onset during active service or within one year of discharge from service, and is not causally or etiologically related to any disease, injury, or incident during service. 6. The Veteran’s arthritis did not have onset during active service or within one year of discharge from service, and is not causally or etiologically related to any disease, injury, or incident during service. 7. The Veteran’s hearing loss has been manifested by no worse than level I hearing loss in both ears. 8. The Veteran’s CAD has not resulted in chronic congestive heart failure, workload of 5 METs or less, or left ventricular dysfunction with an ejection fraction of 50 percent or less. 9. Since December 21, 2011, the Veteran’s PTSD has resulted in occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 10. Prior to July 31, 2013, the Veteran was not prevented from securing and following substantially gainful employment as a result of his service-connected disabilities. 11. Since July 31, 2013, the Veteran has been prevented from securing and following substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for gout have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a disorder characterized by reduced lung capacity have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for arthritis have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for a compensable disability rating for hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100. 8. The criteria for a rating in excess of 30 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.104, DC 7005. 9. Since December 21, 2011, the criteria for an initial rating of 70 percent for PTSD, but no higher, have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9411. 10. Prior to July 31, 2013, the criteria for a TDIU were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. 11. Since July 31, 2013, the criteria for a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1966 to September 1969. The case is on appeal from September 2012 and January 2014 rating decisions. The Board notes that, in October 2013, the RO granted an initial rating of 50 percent for the Veteran’s PTSD. As the Veteran is presumed to be seeking the maximum available benefit for a disability, the entirety of the claim remains before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Murphy v. Shinseki, 26 Vet. App. 510, 514 (2014). In September 2014, the Veteran filed a notice of disagreement (NOD) form disagreeing with the effective date assigned for PTSD in the October 2013 rating decision. He did not specify whether his disagreement was with the effective date of the award of service connection rather than the assignment for the award of the 50 percent rating. Unfortunately, if it was his intent to appeal the effective date for the initial grant of service connection, no earlier rating could be assigned absent an earlier effective date for the underlying grant of service connection. To this extent, an appeal for an earlier effective date for the grant of service connection would amount to an impermissible freestanding earlier effective date claim because the September 2014 NOD was received greater than one year after the September 2012 rating decision granting service connection for PTSD. Rudd v. Nicholson, 20 Vet. App. 296 (2006). If he intended to dispute the effective date for the 50 percent rating, the October 2013 rating decision assigned the 50 percent rating effective from the initial date from which service connection was granted for the disability. Thus, his intent in appealing the effective date is unclear. However, any disagreement with the effective of the 50 percent rating assigned is ultimately part and parcel of his PTSD initial rating claim now on appeal. In this regard, generally a claim for an earlier effective date for the award of a particular disability rating is a distinct issue appealable to the Board. See Hazan v. Gober, 10 Vet. App. 511 (1997). Here, however, the Veteran’s appeal arises from the rating decision granting an initial 50 percent rating for PTSD. The appeal of the effective date for the 50 percent rating is subsumed by the appeal of the claim for a higher initial disability rating because the Board will necessarily be adjudicating the earlier effective date issue. See AB, 6 Vet. App. at 38; see also Fenderson v. West, 12 Vet. App. 119, 125-27 (1999). As such, the Board is not remanding the issue for issuance of a statement of the case (SOC). The Veteran also requested earlier effective dates for CAD and hearing loss evaluations in the September 2014 NOD, but there are no effective dates to contest for these disabilities as no benefits were granted in the January 2014 rating decision. In August and September 2016, the Veteran’s representative submitted additional evidence. The Veteran waived initial RO consideration of the additional evidence. See 38 C.F.R. § 20.1304(c). The Veteran’s representative indicated in the August 2016 submission that the Veteran is permanently and total disability due to his service-connected disabilities. While the RO has not yet addressed this claim, it is considered part of his increased rating claims. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the Board has jurisdiction over this issue. 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). Although the Board is remanding a claim for additional development, remand is not necessary for the issues decided herein, as there is no reasonable possibility that further assistance would substantiate the claims beyond what is already granted. See 38 C.F.R. § 3.159(d). I. New and Material Evidence 1. Whether new and material evidence has been submitted to reopen a claim of service connection for hypertension. By an October 2011 rating decision, a claim of service connection for hypertension was denied. The Veteran was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in November 2012. No new evidence or notice of disagreement was received by VA within one year of the issuance of the October 2011 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for hypertension is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also Westside Cardiology Treatment Records.   II. Service Connection Claims 2. Entitlement to service connection for gout. 3. Entitlement to service connection for sleep apnea. 4. Entitlement to service connection for a disorder characterized by reduced lung capacity. 5. Entitlement to service connection for a right hip disorder. 6. Entitlement to service connection for a left hip disorder. 7. Entitlement to service connection for arthritis. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”—the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases, including arthritis, are presumed to be incurred in or aggravated by service if manifest to a compensable degree within one year of separation from service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258 (2015). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107, 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Facts and Analysis In a November 2012 correspondence, the Veteran filed a claim of service connection for gout, sleep apnea, reduced lung capacity, bilateral hip replacement, and arthritis throughout his body including his back. The Veteran’s service treatment records (STRs) do not contain any reports of, or treatment for, gout, a sleep disorder, breathing difficulties, or musculoskeletal conditions. In addition, during his September 1969 separation examination, the Veteran did not report, and the examiner did not note, the presence of any relevant conditions. Furthermore, during the course of the appeal the Veteran has not reported experiencing any condition related to such claims during his military service or indicated how his present conditions may be related to such service. The Veteran’s post-service VA treatment records reflect that he has been treated for relevant conditions since his discharge from service. In this regard, a private treatment provider noted a diagnosis of gouty arthritis in April 2011. In addition, such records show that he was diagnosed with severe sleep apnea in October 2011. Private treatment records also show that he exhibited decreased lung capacity during testing in October 2012. Furthermore, the Veteran’s post-service treatment records reflect that he has had both hips replaced. However, the Board finds that the Veteran’s gout, sleep apnea, reduced lung capacity, bilateral hip disorders, and arthritis did not occur during service and are not otherwise related to service. In this regard, the Veteran has not asserted, and his STRs do not show, that he experienced such disorders during service. In addition, there is no other evidence of record indicating a nexus between the Veteran’s military service and these conditions. Furthermore, there is no indication that the Veteran’s right or left hip disorders or his arthritis had their onset within one year of his discharge from service. While the Veteran has not been afforded an examination in regard to any of these claims, a mere conclusory claim that a current condition is related to service is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that a VA opinion is not warranted for these claims. Accordingly, the preponderance of the evidence is against the Veteran’s claims of service connection for gout, sleep apnea, a disorder characterized by reduced lung capacity, bilateral hip disorders, and arthritis. Therefore, the benefit-of-the-doubt doctrine is not applicable and service connection for these disorders is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. III. Higher Rating Claims General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 8. Entitlement to a compensable rating for bilateral hearing loss. Specific Legal Criteria Disability evaluations for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Examinations are conducted using the controlled speech discrimination tests together with the results of the pure tone audiometry test. See 38 C.F.R. § 4.85. The results are analyzed using tables contained in 38 C.F.R. § 4.85, DC 6100. The rating schedule for hearing loss provides that evaluations of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 cycles per second (Hertz). To evaluate the degree of disability from defective hearing, the rating schedule established eleven auditory acuity levels designated from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85, DC 6100. 38 C.F.R. § 4.86(a) provides that when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. The provisions of 38 C.F.R. § 4.86(b) provide that when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. Facts and Analysis The Veteran contends that his hearing loss should have a compensable rating. The Veteran was afforded a VA audiological examination in regard to this claim in November 2013. During the examination, the Veteran reported that he experiences difficulty hearing friends and co-workers when they talk to him. The examiner reported the following pure tone thresholds, in decibels: HERTZ 1000 2000 3000 4000 AVG. RIGHT 20 25 45 65 38.75 LEFT 15 20 25 60 30 The average pure tone threshold was 38.75 in the right ear and 30 in the left ear. Speech discrimination revealed scores of 100 percent in both his right ear and left ears. The results correspond to level I hearing loss in the right ear and level I hearing loss in the left ear. When combined, the results reflect a noncompensable disabling evaluation for the Veteran’s hearing loss. 38 C.F.R. § 4.85. In addition, the findings do not show an exceptional pattern of hearing impairment and, thus, 38 C.F.R. § 4.86 is not applicable. 38 C.F.R. §§ 4.85, 4.86, DC 6100. The Board finds a compensable rating for this disability is not warranted at any point during the appeal. Although the Veteran contends that his hearing loss should be rated at a compensable level, the mechanical hearing testing of record shows that his hearing loss is correctly evaluated as noncompensably disabling. Additionally, the functional effects of the hearing loss reported by the Veteran are contemplated by the hearing loss rating schedule. The Board has considered the benefit-of-the-doubt rule. However, because the preponderance of the evidence is against the Veteran’s claim for a compensable rating for hearing loss, the benefit-of-the-doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. Therefore, an initial compensable rating is not warranted. 9. Entitlement to a rating in excess of 30 percent for CAD. Specific Rating Criteria The Veteran’s CAD has been assigned a 60 percent disability rating under DC 7005 of 38 C.F.R. § 4.104. Under DC 7005, a 10 percent rating is warranted when the Veteran experiences a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or if continuous medication is required. 38 C.F.R. § 4.104, DC 7005. A 30 percent rating is warranted when the Veteran experiences a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. A 60 percent rating is warranted when the Veteran experiences a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when the Veteran experiences congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. A Note following the rating code provides if nonservice-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symptoms Facts and Analysis The Veteran contends that his CAD should be rated in excess of 30 percent disabling. The Veteran was afforded a VA examination in regard to this claim in November 2013. The examiner reported that the Veteran has had CAD and stable angina since 2006. The examiner also reported that the Veteran had an acute episode of congestive heart failure in September 2013, but denied that he has chronic congestive heart failure. The examiner further reported that a September 2013 echocardiogram showed that the Veteran has a left ventricular ejection fraction of between 55 and 60 percent. The examiner found that the Veteran experiences dyspnea, fatigue, and angina and estimated his METs level at greater than 5 but less than 7. The examiner also estimated that 40 percent of the Veteran’s METs level limitation is due to CAD and the rest is due to other medical conditions. Based on the foregoing, the Board finds that a rating in excess of 30 percent for CAD is not warranted. In this regard, the evidence does not show that the Veteran has chronic congestive heart failure or a left ventricular ejection fraction of 50 percent or less. He had one episode of acute congestive heart failure, but the 60 percent disability level requires more than one episode. In addition, the Veteran has not been found to have a METs workload between 3 and 5. Furthermore, the November 2013 examiner found that 40 percent of his reduced METs workload is due to his service-connected CAD. Thus, the evidence does not establish CAD symptomatology indicative of a rating in excess of 30 percent. While the record contains evidence that the Veteran’s CAD symptomatology limits his ability to work, as explained below, the Board is granting a TDIU for the combined with the effects of his CAD and PTSD. Accordingly, the Board concludes that the preponderance of evidence is against the Veteran’s claim for a CAD rating in excess of 30 percent, there is no benefit of the doubt to be resolved, and the assignment of an increased rating is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. 10. Entitlement to an initial rating in excess of 50 percent for PTSD. Specific Rating Criteria Under 38 C.F.R. § 4.130, most service-connected mental health disabilities are rated pursuant to the General Rating Formula for Mental Disorders. Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence of record that bears on occupational and social impairment, rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Under DC 9411, a 30 percent rating is assigned for PTSD for 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; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned 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 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted 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 the 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 an inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for 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 ability 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. The Board notes that the records contain various global assessment of functioning (GAF) scores. However, GAF scores have been found to be unreliable and not sufficient evidence for rating a psychiatric disorder. See Golden v. Shulkin, 29 Vet. App. 221, 226 (2018). The effective date of an award based on an original claim or a claim reopened after final adjudication shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; Rodriguez v. West, 189 F.3d 1351, 1354 (Fed. Cir. 1999). Facts and Analysis The Veteran contends that his PTSD should have an initial rating in excess of 50 percent. In this regard, in August 2012, the Veteran submitted statements from a friend, a coworker, and his wife. The Veteran’s friend reported that the Veteran has mood swings and that can cause him to become violent. He also reported that the Veteran is uncomfortable around other people and prefers to work by himself. The Veteran’s coworker reported that the Veteran is short tempered and often becomes angry. He also reported that the Veteran likes to work alone and becomes frustrated when people try to give him instruction. The Veteran’s wife reported that the Veteran is hypervigilant and startles easily. She also reported that he experiences chronic sleep impairment and flashbacks to his time in Vietnam. The Veteran was first afforded a VA examination in regard to this claim in August 2012. The Veteran reported that he has outbursts of anger during which he throws objects and becomes verbally abusive with his friends and family. The examiner found that the Veteran’s PTSD results in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. However, the examiner also reported that his PTSD results in symptoms of road rage, intrusive memories, depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, impaired judgment and impulse control, disturbances of motivation and mood, difficulty adapting to stressful circumstances, an inability to establish and maintain effective relationships, and suicidal ideation. The file also contains VA mental health treatment records from 2013 through 2016. These records reflect that treatment providers found that the Veteran was not found to demonstrate a risk of harm to himself or others. These records also show that the Veteran was groomed appropriately and denied experiencing hallucinations during treatment. In addition, in July 2014, a VA psychologist who treated the Veteran wrote a letter. The VA psychologist reported that the Veteran loses his temper at even small stressors and left his last job in 2013 due to an inability to interact with coworkers. He also reported that the Veteran’s prognosis for a full recovery from PTSD is poor. Thereafter, in August 2016, the Veteran’s representative submitted a private psychiatric evaluation of the Veteran conducted in June 2015. The private psychologist noted that the Veteran has been married for 44 years and lives with his wife, daughter, and grandson. She reported that the Veteran’s PTSD results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The psychologist found that the Veteran experiences the PTSD symptoms reported by the August 2012 examiner and additionally reported the presence of persistent delusions and hallucinations and an intermittent inability to perform the activities of daily living including maintenance of personal hygiene. After engaging in a holistic analysis assessing the severity, frequency and duration of the signs and symptoms of the Veteran’s PTSD, recognizing that the symptoms listed in the rating criteria are non-exhaustive examples and when looking at the effects determining the impairment level, the Board finds that an initial rating of 70 percent is warranted as of December 21, 2011. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013); Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Mauerhan v. Principi, 16 Vet. App. 436 442 (2002). In this regard, the first assessment of the Veteran’s PTSD performed in August 2012 shows that he experiences symptoms indicative of a 70 percent rating including suicidal ideation, impaired impulse control including unprovoked irritability with periods of violence, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. This level of impairment is supported by the July 2014 VA psychologist’s letter and the June 2015 private psychologist’s assessment. While an initial 70 percent rating is warranted, the Veteran’s PTSD does not warrant a higher rating at any time during the period on appeal. In this regard, the evidence of record does not show that the Veteran has experienced gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, or memory loss for names of close relatives, occupation, or his own name. In addition, the Veteran’s VA treatment records reflect that his treatment providers have not found that he presents a danger to hurting himself or others. Furthermore, while the Veteran experiences social impairment, he has continued to live with his wife of 44 years. To the extent that the Veteran’s PTSD prevents him from working, as discussed below, the Board is granting a TDIU for the combined with the effects of his CAD and PTSD. The Board herein below remands the appeal for an earlier effective date for the award of service connection for PTSD. The Board takes no stance on that issue nor, in reaching the instant outcome, the appropriate disability rating to be assigned should service connection for PTSD be granted from an earlier effective date. In sum, an initial 70 percent rating is warranted for PTSD since December 21, 2011. However, as the preponderance of the evidence is against an even higher initial rating at any point during the appeal period or an earlier effective date, the benefit-of-the-doubt doctrine is not further applicable, and any additional grant of benefits is not warranted for such disability. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. III. TDIU 11. Entitlement to a TDIU prior to July 31, 2013. 12. Entitlement to a TDIU since July 31, 2013. Legal Criteria 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). For the purpose of meeting these schedular criteria, disabilities affecting a single body system, e.g. orthopedic, will be considered as one disability. Id. 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. at 452 (2009). 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). A veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Facts and Analysis The Veteran contends that he is unable to work due to his service-connected disabilities. The Veteran has met the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a) since December 21, 2011. In this regard, he is service connected for CAD evaluated as 30 percent disabling since August 18, 2010; tinnitus evaluated as 10 percent disabling since October 18, 2010; bilateral hearing loss evaluated as noncompensable since October 18, 2010; and PTSD evaluated as 70 percent disabling since December 21, 2011. Thus, the question for the Board is whether he has been unable to work due to his service-connected disabilities. On this question, the Veteran did not complete a formal TDIU application. Thus, he did not provide the information asked on that form relating to his work history. Nonetheless, this information is reflected elsewhere in the record. Most specifically, he informed a VA examiner in November 2013 that he retired from work on July 31, 2013. In August 2016, the Veteran’s representative submitted articles discussing the affect PTSD has on the ability of people to work. The Veteran’s representative also submitted a June 2016 report from a vocational consultant. The consultant reported that the Veteran is unable to work due to his service-connected CAD, PTSD, tinnitus, and hearing loss. She found that the Veteran has a combination of physical and emotional conditions that interact in terms of severity and result in major limitations in his ability to maintain substantial gainful employment. During the August 2012 VA psychiatric examination, the Veteran reported performing menial part time jobs prior to entering the military. He also reported working on test ranges for 5 years after his discharge and then working as a painter for 35 years. Thereafter, during the November 2013 VA heart examination, the Veteran reported having difficulty walking in June 2013 and retiring July 31, 2013 after working for 28 years as a painter. As described above, the evidence of record reflects that the Veteran’s PTSD has resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In addition, in a July 2014 questionnaire, the Veteran’s private physician who treated him for CAD for many years reported that he is unable to stand, walk, or sit for 2 hours or more during a work day. He also reported that the Veteran is unable to carry 10 pounds and would need to be absent from work or leave early 3 days or more per month due to his disabilities. The Board finds that the Veteran has been unable to secure or follow a substantially gainful occupation as a result of the combined effects of his service-connected disabilities since July 31, 2013. As discussed above, the Veteran’s treating psychologist explained that the Veteran left his last job due to an inability to interact with his coworkers. In addition, the Veteran’s private physician explained the physical limitations he experiences due to his CAD. Furthermore, the Veteran’s PTSD prevents him from obtaining work in sedentary occupations that require regular interaction with coworkers and supervisors. This conclusion is also supported by the findings of the June 2016 vocational consultant. However, as the Veteran continued to maintain gainful employment prior to July 31, 2013, an earlier effective date for a TDIU is not warranted. Thus, the Board finds that the proper effective date for the TDIU award is July November 18, 2008. This is the date service connection went into effect for the depressive disorder. Prior to this date, the Board finds that a TDIU is not warranted as the Veteran was service connected solely for the foot and breast disorders, which combined to 10 percent disabling. The Board has found that the physical and mental impairments have combined to preclude the Veteran from securing and following substantially gainful employment. Accordingly, the preponderance of the evidence is against a TDIU prior to when service connection went into effect for depressive disorder. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran has been unable to secure or follow a substantially gainful occupation as a result of the combined effects of his service-connected disabilities since July 31, 2013. Prior to this date, the preponderance of the evidence is against a TDIU because the Veteran was still maintaining gainful employment. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as due to herbicide exposure. In October 2010, the Veteran claimed service connection for hypertension and indicated that this condition was caused by his service in Vietnam. He also indicated that he was exposed to herbicide during such service. The Veteran’s STRs show that he served in Vietnam and a July 2007 post-service private treatment record reflects that he has been diagnosed with hypertension at least since that time. However, a medical opinion has not yet been obtained in regard to this claim. The Board finds that remand is required to address the nature and etiology of his hypertension. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). This claim is REMANDED for the following action: Schedule the Veteran for an examination by an appropriate medical professional to determine the nature and etiology of his hypertension. The entire claims file should be reviewed by the examiner. Thereafter, the examiner is to provide opinions as to: (a.) Whether it is at least as likely as not that the Veteran’s hypertension had onset during service or within one year of discharge from service or is otherwise related to service. (b) Whether it is at least as likely as not that the Veteran’s hypertension is related to his confirmed in-service herbicide exposure. In answering this question, the examiner is asked to disregard whether the disorder is one for which a "presumption" is established and, instead, to answer whether the Veteran’s hypertension is a result of Agent Orange exposure even though it is not on the list of "presumptive" diseases. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Jimerfield, Associate Counsel