Citation Nr: 18149078 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-16 479 DATE: November 8, 2018 ORDER Entitlement to service connection for cerebrovascular accident (CVA) to include as secondary service connected disability of posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial evaluation of 50 percent but no higher for PTSD is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran experienced a CVA that was less likely than not (less than 50% probability) proximately due to the result of or aggravated by the Veteran’s service connected PTSD and it is not otherwise shown to be related to his active service. 2. The Veteran suffers from occupational and social impairment with reduced reliability and productivity due to such symptoms as impairment of short-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, but does not exhibit occupational and social impairment with deficiencies in most areas due to symptoms such as suicidal ideation, obsessional rituals, near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for CVA to include as secondary to service connected disability of PTSD have not been met. 38 U.S.C. § 1101; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (a). 2. The criteria for entitlement to an initial evaluation of 50 percent but no higher for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.159, 3.321, 4.130, Diagnostic Codes (DC) 9411-9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from May 1972 through May 1975, including service in the Republic of Vietnam. He was honorably discharged. The CVA matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The PTSD matter comes to Board on appeal from a September 2012 rating decision issued by the VA RO in Seattle, Washington. 1. Entitlement to service connection for cerebrovascular accident (CVA) to include as secondary service connected disability of PTSD. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). For Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as brain hemorrhage and brain thrombosis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In some cases, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). The Veteran then suffered a stroke affecting the medial left temporal lobe in June 2013. He was discharged the following day. Prior to his 2013 stroke, the Veteran was diagnosed with hypertension, hyperlipidemia, and tobacco use disorder. The Veteran was prescribed medication in response to hypertension and hyperlipidemia. He states that his stroke was caused or aggravated by his service connected PTSD. The Veteran was given a VA examination in August 2016. The VA physician opined the CVA was less likely than not (less than 50% probability) proximately due to, the result of, or aggravated by the Veteran’s service-connected PTSD. The physician reasoned the Veteran has been diagnosed with hypertension, is a smoker and his blood pressure is not well controlled. The VA physician highlighted four major treatable risk factors for stroke: (1) hypertension, (2) diabetes mellitus, (3) smoking, and (4) dyslipidemia. Additionally, none of the four risk factors are service connected disabilities. The Veteran and his spouse have generally alleged on his behalf that this disability was the result of his service-connected PTSD. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The question regarding the potential relationship between the Veteran’s CVA and any instance of his service-connected condition to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Specifically, while the Veteran is competent to describe his current symptoms and his wife is competent to describe her observations of the Veteran’s symptoms, the Board accords their statements regarding the etiology of such disorders little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issued. Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. There is no suggestion that the Veteran and/or his attorney have had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran, and/or his representative are nonprobative evidence. The Veteran’s attorney appears to argue that there is a relationship between PTSD and CVA. Specifically, he included a one page excerpt of an article from The Open Cardiovascular Medicine Journal that states that persons with PTSD “may have an increased risk of coronary heart disease and possibly thromboembolic stroke. The evidence is not persuasive. In this regard, medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159 (a)(1). However, treatise evidence must “not simply provide speculative generic statements not relevant to the [claimant]’s claim.” Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, “standing alone,” must discuss “generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Wallin. In this case, the medical excerpt only provides general information as to the possibility that a relationship may exist between PTSD and thromboembolic stroke. These excerpts are not accompanied by any corresponding clinical evidence specific to the Veteran and do not suggest that the CVA was caused or aggravated by his service-connected PTSD with a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Moreover, he indication of that there “may” be a relationship between PTSD and thromboembolic stroke is speculative in its nature. The Court has long held that speculative carry little evidentiary value. As such, the Board finds this information to be overbroad and not relevant as to the matter for consideration and, therefore, is not probative to this case. See also Wallin; Sacks. The Board finds no competent medical evidence linking CVA to PTSD. The CVA did not manifest within one year of service discharge; and is not caused or aggravated by the Veteran’s service-connected PTSD. There is no evidence of continuity of symptomatology after service. The only indication of CVA occurred in 2013. Consequently, service connection for such disorder is not warranted. The Board also finds the Veteran has not met the requirements to entitlement for direct service connection. The Veteran has met the first Shedden requirement because he experienced a CVA. However, the remaining two Shedden requirements have not been fulfilled. Service treatment records and post-service records do not provide any evidence of an in-service incurrence or aggravation of a CVA. Additionally, there is no evidence linking the CVA with an in-service incurrence or aggravation of the CVA. In light of the foregoing, service connection must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims of entitlement to service connection for a CVA. As such, that doctrine is not applicable in the instant claim, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert. On February 28, 2017, the Veteran’s representative requested the Board order a VA opinion considering (1) studies correlating PTSD with stroke and hypertension and (2) smoking to cope with symptoms of PTSD. A thorough review of the Veteran’s file reveals he has not expressed an intent to apply for service connection for hypertension or smoking related illnesses secondary to service connected PTSD. If the Veteran wishes to pursue a claim for service connection for hypertension or tobacco/nicotine dependence, then he should do so through the appropriate process for filing a claim. 2. Entitlement to an initial evaluation of 50 percent but no higher for PTSD. Disability evaluations (ratings) are determined by evaluating 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 the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical and industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Evaluations for various psychiatric disabilities are assigned pursuant to 38 C.F.R. § 4.130. A rating of 50 percent is assigned for 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A rating of 70 percent is assigned 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; 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 inability to establish and maintain effective relationships. Id. 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 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. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has embraced the Mauerhan Court’s interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) provided additional guidance in rating psychiatric disability. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Specifically, the Federal Circuit emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words “such as” that precede each list of symptoms. Id. at 2. It held that 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. Id. at 4. Other language in the decision indicates that the phrase “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. Service connection for PTSD was granted in a September 2012 rating decision. A 30 percent disability rating was assigned from June 30, 2007, which was the date of claim. The Veteran appealed that rating. The Veteran has been married three times and divorced twice. He has adult children. The Veteran has some college education and is currently unemployed. He has not worked since 2009 and has had a tumultuous work history. He has been terminated from 14 jobs due to conflict with employers or co-workers beginning in 1975 through 2009. A medical report from the Multnomah, Oregon “Vet Center” in 1996 indicated he sought treatment for the following symptoms: Anger and lack of patience towards children; disorganized thinking; pending divorce; obsessive thinking; suicidal thoughts and possible PTSD. The Veteran did not have a plan to commit suicide. Ultimately, the Vet Center closed the file due to the Veteran’s failure to respond to letters and missed appointments. The Veteran was given a VA examination in 2007. During the examination, the Veteran was friendly, attentive, and cooperative. The Veteran’s thought process was “unremarkable.” He was aware of the outcomes of his behavior and his intelligence is above average. The Veteran suffered from nightmares and sleep impairment. At the time, however, there was no finding that he behaved inappropriately or suffered from panic attacks, impulse control or maintaining personal hygiene. The examiner determined the Veteran had obsessive compulsive traits which did not rise to the level of obsessive compulsive disorder. Additionally, the Veteran was sober from drugs and alcohol for five years and had a good attitude about recovery. The examiner opined the Veteran’s symptoms did not surpass the threshold for traumatic stress. Medical records from 2010 indicate the Veteran had some limitations in his ability to understand and remember detailed instructions, carry out detailed instructions, maintain attention and concentration for extended periods, interact appropriately with the general public, and respond appropriately to changes in the work setting. The physician opined the Veteran “would have some difficulty interacting with supervisors and coworkers, as he gets easily startled and feels hypervigilant. He may not be able to perform work activities on a consistent basis without getting additional help from supervisors.” The examiner stated the Veteran’s PTSD and disturbed sleep would make it difficult to maintain prompt and regular attendance at work. Finally, the examiner found that workplace stress would aggravate the Veteran’s condition. The Veteran was given an additional VA examination for evaluating PTSD in May 2011. The Veteran reported he felt distant from his friends and family, yet he would see friends approximately once a month and was actively involved with his family. Although his daughters only spoke with him once per month, he maintained a relationship with them. The Veteran spoke freely and spontaneously, he was logical and understandable. The examiner found no signs of psychopathology such as hallucinations, delusions, or preoccupations. The Veteran correctly interpreted a proverb. He was diagnosed with mild PTSD caused by fear of military or terrorist activity. It was also determined that the Veteran suffered mild occupational and social impairment from PTSD. A June 2011 application for Social Security benefits confirmed the Veteran was able to take care of his hygiene needs. Although he needed reminders from his wife to shower, he completed these tasks on his own. The Veteran was able to follow written directions “exactly – to a fault.” He found verbal instructions more difficult to follow. The Veteran experienced little pleasure engaging in activities nearly every day and felt depressed, hopeless, and “down” often. A final VA examination was conducted in April 2016. The Veteran experienced depressed mood, anxiety and suspiciousness. He was alert, cooperative, and spoke with regular volume and rate. He did not suffer from hallucinations, delusions, obsessions, suicidal or homicidal ideation. Thought processes were logical and goal directed. The Veteran experienced temper flare-ups which include screaming and profanity. The examiner subjected the Veteran to the Minnesota Multiphasic Personality Inventory-2. The interpretation of the Veteran’s results indicate he displays depression, restlessness and agitation due to situational stress. The exam interpretation reveal the Veteran has poor behavior control and exaggerated expressions of guilt. The examiner considered the Veteran’s spouse’s lay statements regarding the Veteran’s explosive anger, remorse, depression, inability to maintain relationships with family members and neighbors, arguments with others. The examiner also considered the spouse’s observations of the Veteran kicking, swinging his arms, and yelling while asleep. The examiner concluded the Veteran experienced “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.” Importantly, the examiner also found the symptoms may be controlled by medication. In addition to relevant medical evidence, the Veteran submitted several lay witness statements. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Veteran’s statement described traumatic events he experienced in service including a description of the recurring nightmares. The Veteran competent and credible to make these statements. The statements have some probative value since these nightmares have reoccurred for 40 years. The Veteran’s wife submitted four lay statements. The first and second statements submitted in 2009 are virtually identical. The third and fourth statements are similar in nature. The first two statements discuss the Veteran’s experience with depression, temper flare-ups, and substance abuse. The third statement recounts observing the Veteran alienating friends and family; his explosive anger towards strangers and neighbors; chronic nightmares; inability to sleep regularly; road rage; lack of patience; feelings of abandonment by his children; depression; increasing chemical dependency; and rage while watching sports. The fourth statement repeats many of the observations described in the third statement. The Board finds statements made by the Veteran’s wife to be competent and credible. Her statements regarding the Veteran’s behaviour have some probative value due to her close relationship with the Veteran. Some of her observations have been incorporated by some medical examiners in reaching their conclusions. The Veteran’s former employer and friend submitted a statement in July 2009 describing the Veteran’s personality change after his service in Army. The lay witness described the Veteran’s conflicts with other workers. Additionally, the witness observed the Veteran exhibit anxious behavior, a quick temper, depression, and an inability to discuss his time in the Army with his family or friends. This statement is competent and credible. His statements regarding the Veteran’s behaviour have some value and corroborate the medical findings. Applying the relevant rating criteria, the Board finds that an evaluation of 50 percent is warranted. There is evidence that the Veteran suffers from occupational and social impairment with reduced reliability and productivity due to such symptoms as impairment of short-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran’s symptoms have created difficulty in maintaining effective work and social relationships. The record is replete with evidence that supports a finding the Veteran has experienced and continues to experience occupational and social impairment with reduced reliability and productivity due to his symptoms. Some of the Veteran’s symptoms have existed for decades. Specifically, the Veteran experienced strained relationship with his former spouses, children, employers and co-workers. The Board acknowledges that the record reflects the Veteran was terminated from 14 jobs; in 2007 the Veteran experienced depression and chronic nightmares; in 2010 he experienced little interest or pleasure nearly every day and felt depressed several days per week; in 2016 the Veteran experienced anxiety, outbursts of anger, inappropriate behavior, lack of patience, and strained relationships with friends and neighbors. Competent medical evidence dating back to 2010 specifically states the Veteran “would have some difficulty interacting with supervisors and coworkers, as he gets easily startled and feels hypervigilant. He may not be able to perform work activities on a consistent basis without getting additional help from supervisors.” These symptoms and complaints are contemplated in the 50 percent rating. An evaluation of 70 percent is not warranted, however. There is no evidence the Veteran suffers from occupational and social impairment, with deficiencies in most areas, such as work school, family relationships, judgment, thinking or mood is not shown. While not outcome determinative, the Veteran has not displayed symptoms 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; and an inability to maintain effective relationships. The evidence simply does not establish a severity of symptoms that is commensurate with a 70 percent rating. The Veteran has demonstrated that he is capable of engaging in several favorable relationships. Indeed, the record shows that the Veteran enjoys a loving, caring, and supportive relationship with his wife. Such belies the notion of there being an inability to maintain effective relationships. Consideration is made to the report made in 2011 that the Veteran experienced suicidal thoughts, and that the Court has held that the presence of suicidal ideation in and of itself can support the assignment of a 70 percent rating. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). However, unlike the appellant in Bankhead, who had an established history of suicidal ideation, the Veteran in the present case had only the one report of suicidal ideation in past decade. His single report of suicidal ideation is deemed an outlier and not representative of the overall severity of his PTSD. Consideration has also been given to the Veteran’s personal belief that a higher rating should be assigned. He is competent to report his current psychiatric symptoms as these observations come to them through their senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran’s assessment of the severity of his disability. The examinations also took into account the Veteran’s subjective statements with regard to the severity of his psychiatric disability. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial evaluation higher than 50 percent for his psychiatric disability. The Board has considered the Veteran’s representative request to remand this matter for an additional VA examination. He alleges that the examiner displayed an improper attitude towards PTSD group therapy. In this regard, the Veteran’s spouse stated the examiner “didn’t believe that attending group counseling with Veteran peers was a good idea.” She further stated that the examiner believes that they just need to ‘get over it, and quit dwelling on the past and move forward.’” The Veteran stated the examiner said, “sometimes veterans just need to get over it and move on with their lives.” They intimate that the examiner’s attitude eschewed the findings of the examination. The Board does not agree. The VA examination in question was conducted by a licensed psychiatrist. The examiner reviewed the Veteran’s prior medical history and examinations. The report includes numerous quotations from the Veteran’s claim file, and the examiner provided detailed summaries from his in-person examination of the Veteran. The examiner also conducted additional testing to better understand the Veteran’s symptoms, personality, and functioning. The examination report is sufficiently detailed and the conclusions are supported with adequate data and rationales. There is nothing in the report to suggest that the examiner was prejudiced in his findings. Accordingly, the Board deems the April 2016 VA examination adequate for adjudication purposes. REASONS FOR REMAND 1. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Veteran has asserted, during several psychiatric and medical examinations, that his disability precludes him from obtaining and maintaining substantial gainful employment, and therefore a claim for a TDIU has been inferred. Rice v. Shinseki, 22 Vet. App. 447 (2009). Nonetheless, it does not appear that the Veteran has been afforded written notice of the information necessary to substantiate TDIU claim or the appropriate claim form. In order for the Veteran’s TDIU to be fully and fairly adjudicated it is necessary that he have the opportunity to provide the information necessary to substantiate the claim. The matter is REMANDED for the following action: 1. Provide the Veteran with the appropriate notice accompanied by the claims forms necessary to file and complete a TDIU claim. 2. After the requested development has been completed, the RO shall review and adjudicate the claim for TDIU. Consideration should be given as to whether TDIU is warranted on an extraschedular basis, to include referral to the Director of Compensation and Pension. If the claim is denied, the Veteran and his representative should be furnished a Supplemental Statement of the Case and provided with the appropriate opportunity to respond. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Mahmoudi, Associate Counsel