Citation Nr: 18153230 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 16-50 035 DATE: November 28, 2018 ORDER New and material evidence has been received to reopen a claim for service connection for a sleep apnea disability. New and material evidence having not been submitted, the Veteran’s application to reopen the claim of entitlement to service connection for a hypertension disability is denied. Entitlement to service connection for a sleep apnea is granted. Entitlement to service connection for a low back disability is denied. Entitlement to a 70 percent rating for posttraumatic stress disorder (PTSD) is granted. Entitlement to a rating in excess of 20 percent for diabetes mellitus is denied. Entitlement to an effective date earlier than October 27, 2014 for the award of a 70 percent rating for PTSD is denied. Entitlement to an effective date earlier than January 21, 2011 for the award of a 20 percent rating for PTSD is denied. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. In an unappealed October 2009 rating decision, the RO, in part, denied service connection for a sleep apnea disability and hypertension. The Veteran did not timely perfect an appeal of these determinations, and no new and material evidence was received within one year of notice of this decision. 2. Evidence received since the October 2009 rating decision including an October 2016 Disabilities Benefits Questionnaire (DBQ) noting that the Veteran’s service-connected PTSD aggravated his sleep apnea is not cumulative or redundant of evidence previously of record, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a sleep apnea disability. 3. The evidence received since the October 2009 denial of service connection for a hypertension disability includes evidence that was not previously of record, but it does not raise a reasonable possibility of substantiating the claim. 4. Resolving reasonable doubt in the Veteran’s favor, the evidence of record favors a finding that the Veteran’s sleep apnea disability is aggravated by his service-connected PTSD. 5. The Veteran’s current low back disability was not manifest in service, was not manifest within one year of separation and is not related to service. 6. The impairment from the Veteran’s PTSD more closely approximates deficiencies in most areas. 7. The competent medical evidence of record indicates that the Veteran’s type II diabetes mellitus treatment does not require regulation of activities. 8. The Veteran filed a new claim for an increased rating for his PTSD disability that was received on October 27, 2014. 9. It was not factually ascertainable at any time between October 27, 2013 and October 27, 2014, that the Veteran underwent an increase in the severity of his PTSD disability. 10. In an October 2011 rating decision, the RO assigned an effective date of January 11, 2011, for a 20 percent rating for diabetes mellitus based on a January 11, 2011 treatment record. 11. There was no formal or informal claim for an increased rating prior to January 11, 2011 nor is there any evidence of treatment showing an increase in severity within the year preceding January 11, 2011, thus, it is not factually ascertainable that the Veteran’s diabetes mellitus disability was 20 percent disabling prior to January 11, 2011. 12. With full consideration of the Veteran’s educational and occupational background, the evidence of record supports a finding that his service-connected PTSD disability renders him unable to secure and follow substantially gainful employment. CONCLUSIONS OF LAW 1. The October 2009 rating decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.113 (2017). 2. New and material evidence has been received since the October 2009 denial, and the claim of entitlement to service connection for a sleep apnea disability is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for reopening the claim for service connection for hypertension have not been met. 38 U.S.C. § 5108 (West 2012); 38 C.F.R. § 3.156 (2017). 4. The criteria for entitlement to service connection for a sleep apnea disability are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 5. A low back disability was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 6. The criteria for a 70 percent disability evaluation, but no higher, for PTSD are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2017). 7. The criteria for a rating in excess of 20 percent for type II diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). 8. The criteria for an effective date, earlier than October 27, 2014, for a 70 percent rating for the Veteran’s PTSD are not met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.114(a), 3.400 (2017). 9. The criteria for an effective date, earlier than January 11, 2011, for a 20 percent rating for the Veteran’s diabetes mellitus are not met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.114(a), 3.400 (2017). 10. The criteria for a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1966 to July 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board also notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims (“Court”) held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, in an April 2017 correspondence, the Veteran’s representative indicated that the Veteran was currently unable to work as he was permanently disabled. As a result, the Board finds that a TDIU claim has been raised by the record and the issue is added to the issues on appeal. Since the issuance of the October 2016 statement of the case, additional evidence has been added to the Veteran’s claims file. In April 2017, the Veteran’s representative waived consideration of this evidence by the AOJ. Claim to Reopen Laws and Regulations The Veteran filed a claim for service connection for hypertension which was denied in an October 2009 rating decision on the basis that the Veteran’s hypertension was not secondary to herbicide exposure or his service-connected PTSD. As the Veteran did not appeal the October 2009 rating decision, that decision is now final based on the evidence then of record. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Accordingly, the Veteran is required to submit new and material evidence to reopen the claims for service connection for hypertension. 38 U.S.C. § 5108. The Veteran sought to reopen his claim for service connection for hypertension in October 2014. VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). 38 C.F.R. § 3.156(a) defines “new” evidence as evidence not previously submitted to agency decision makers and “material” evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). In determining whether new and material evidence has been received, VA must initially decide whether evidence received since the prior final denial is, in fact, new. As indicated by the regulation cited above, and by judicial case law, “new” evidence is that which was not of record at the time of the last final disallowance (on any basis) of the claim, and is not duplicative or “merely cumulative” of other evidence then of record. This analysis is undertaken by comparing the newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996). Here, the last final denial of the claim is the October 2009 rating decision. Furthermore, for purposes of the “new and material” analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). Evidence received since the October 2009 rating decision includes VA treatment records, private treatment records and a March 2014 VA examination. A review of the VA and private treatment records reveals that they document ongoing treatment for the Veteran’s hypertension disability. However, they contain no references to the Veteran’s military service to include exposure to herbicides or as secondary to a service-connected disability. Additionally, the records do not contain any statements, lay or medical, in support of a nexus between the Veteran’s hypertension disability and his military service. Thus, while these records are considered new, the Board finds that they are not material. 38 C.F.R. § 3.156(a). Finally, there is a new March 2014 VA examination report for the Veteran’s service-connected diabetes mellitus. However, the VA examiner did not provide a potential link to the Veteran’s service as the examiner specifically opined that the Veteran’s hypertension was not caused or aggravated by his service-connected diabetes mellitus. As this evidence does not support a nexus between the Veteran’s hypertension disability and his military service, to include as secondary to a service-connected disability, it is not material. 38 C.F.R. § 3.156(a). As a result, the Board finds that the evidence received since the October 2009 rating decision is new as it was not of record at the time of the prior denial, but the newly submitted evidence is not material as it is cumulative and redundant in nature of the record in October 2009. To the extent that the evidence relates to the reason the claim was previously denied, the new evidence does not raise a reasonable possibility of substantiating the claim for service connection for hypertension. Significantly, competent evidence that any current hypertension disability is related to service to include as secondary to herbicide exposure or secondary to a service-connected disability has not been added to the record. Overall, there is no competent evidence or opinion suggesting that any current hypertension disability is in any way related to his service. Accordingly, the Veteran’s request to reopen the previously disallowed claim of entitlement to service connection for hypertension is denied because none of the newly submitted evidence pertains to the reasons for the prior denial nor raises the reasonable possibility of substantiating the Veteran’s underlying claim. See 38 C.F.R. § 3.156(a) (2017). As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claim of service connection for hypertension, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). In sum, absent any new and material evidence showing that the hypertension disability is due to service, to include as secondary to a service-connected disability, the claim for service connection for hypertension cannot be reopened. See 38 C.F.R. § 3.156(a) (2017). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include arthritis may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 1. Sleep Apnea Factual Background and Analysis On a July 2010 VA examination for PTSD, the examiner noted that the Veteran’s sleep apnea was not caused by or a result of his PTSD but impacted his sleep quality. In August 2016, a private physician provided a DBQ for sleep apnea. The physician noted that a sleep study in 2008 revealed obstructive sleep apnea which has required use of a CPAP machine. The Veteran reported that his CPAP machine caused him to feel trapped and claustrophobic. It made his anxiety much worse and exacerbated his PTSD symptoms. The physician opined that based on his interview of the Veteran, a review of the medical records and supporting medical literature, it was more likely than not that the Veteran’s service-connected PTSD aided in the development of and aggravated the Veteran’s obstructive sleep apnea. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for a sleep apnea disability as secondary to his service-connected PTSD disability is warranted. The Veteran’s medical record shows that he has been diagnosed with obstructive sleep apnea. Accordingly, as there are current diagnoses of a heart disability, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Having reviewed the record, the Board finds there is at least an approximate balance of evidence as to whether the Veteran has current sleep apnea disability that is secondary to his service-connected PTSD disability. Notably, the July 2010 VA examiner noted that the Veteran’s sleep apnea was not caused by or a result of his PTSD but impacted his sleep quality. However, this examiner did not address whether the Veteran’s sleep apnea disability was aggravated by the Veteran’s service-connected PTSD disability. In contrast, the August 2016 physician specifically addressed aggravation as he opined that it was more likely than not that the Veteran’s service-connected PTSD aided in the development of and had aggravated the Veteran’s obstructive sleep apnea. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran had a current sleep apnea disability that was caused or aggravated by his service-connected PTSD disability. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a sleep apnea disability as secondary to his service-connected PTSD disability is granted. See 38 U.S.C. § 5107(b). 2. Low Back Factual Background and Analysis The Veteran’s service treatment records are negative for complaints, treatments or diagnoses of a low back disability. The Veteran underwent a VA orthopedic examination in November 1974 for residuals of gunshot wounds to the left thigh and left chest. The examiner noted that there were no other complaints and no diagnoses related to a low back disability were provided. An August 2016 VA treatment record noted low back pain and a diagnosis of lumbar spondylosis. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for a low back disability is not warranted. As there is a current diagnosis of lumbar spondylosis, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). As noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such disease is shown to be manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for lumbar spondylosis on a presumptive basis is not warranted as the record does not show evidence of lumbar spondylosis within one year of the Veteran’s separation from active duty. Notably, a November 1974 VA examination which took place over 5 years after the Veteran’s separation from active duty was negative for complaints, treatments or diagnoses related to a low back disability. Accordingly, service connection for a low back disability on a presumptive basis is not warranted as a chronic disease did not manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. To the extent that the Veteran is asserting that he experienced back pain and continuing symptoms thereafter, the Board acknowledges that a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, as the Veteran was not diagnosed with a low back disability until many years after service, no complaints or findings were noted during the course of his medical separation, and there was a significant period between his service injuries and his post-service complaints where the medical record was silent for complaints of a low back disability, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Regarding service connection on a direct basis, the Board again notes that the Veteran’s service treatment records are negative for complaints or treatments of a low back disability. Further, there is no competent evidence or opinion even suggesting that there exists a medical nexus between a current low back disability and the Veteran’s service and neither the Veteran nor his representative have presented or identified any such existing medical evidence or opinion. The Board finds that the competent evidence of record, while showing the currently diagnosed low back disability, does not demonstrate that the Veteran’s low back disability is related to the Veteran’s service. The Board also notes that the Veteran was not provided with a VA examination and opinion to assess the current nature and etiology of his claimed low back disability. However, VA need not conduct an examination with respect to the claims on appeal, as information and evidence of record contains sufficient competent medical evidence to decide the claims. See 38 C.F.R. § 3.159(c) (4). Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Simply stated, the standards of McLendon are not met in this case as there is no credible evidence that the low back disability manifested in service or within a year of separation from service and there is also no competent evidence suggesting that this disability is otherwise associated to service. Thus, remand for a VA examination is not necessary. The Board notes the Veteran and his representative’s contentions regarding the etiology of his claimed low back disability. To the extent that the Veteran and his representative themselves contend that a medical relationship exists between his claimed low back disability and his service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that a low back disability is not a disability subject to lay diagnosis as this diagnosis requires medical training. More significantly, the Veteran and his representative do not have the medical expertise to provide an opinion regarding the claimed low back disability etiology. 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 issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Thus, the Veteran and his representative’s assertions that there is a relationship between his claimed low back disability and his service are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). Increased Ratings Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2017). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2017). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2017). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his PTSD and diabetes mellitus. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. His statements have been consistent with the medical evidence of record, and are probative for resolving the matters on appeal. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. 1. PTSD The Veteran filed a claim for an increased rating for his service-connected PTSD which was received by VA in October 2014. The Veteran currently has a 50 percent disability rating for PTSD under Diagnostic Code 9411, effective October 27, 2014. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula. See 38 C.F.R. § 4.130. Under the general rating formula for mental disorders, a 50 percent rating requires 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 rating requires 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 affected 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 worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is 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. Id. The evidence considered in determining the level of impairment for psychiatric disorders under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the rating code. Disability ratings are assigned according to the manifestation of particular symptoms, but the use of the term “such as” in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment from psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2017). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some 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, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more 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]. Scores ranging from 41 to 50 reflect 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]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [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 other children, is defiant at home, and is failing at school]. VA has changed its regulations, and now requires use of DSM-5 effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093 (Aug. 4, 2014). As the Veteran’s case was certified to the Board after August 4, 2014, DSM-5 applies, and GAF scores are no longer used in evaluation of psychiatric disorder. Id. However, the examiner’s discussion of symptoms associated with any assigned score would still be useful in evaluation of psychiatric disabilities. Factual Background and Analysis The Veteran underwent a VA examination in March 2015. The examiner summarized the Veteran’s level of occupational and social impairment with regard to all mental diagnoses as occupational and social impairment with reduced reliability and productivity. The Veteran reported being married twice as his first wife of 42 years passed away from cancer in 2012 and he remarried in 2014. He indicated this his son did not want to stay in touch. He reported having very few friends as he stayed to himself. He used to hunt in fish but now mostly went out to his yard to stay busy. He went to church twice a month and had no suicide attempts. He noted that he was let go at his job in the maintenance department due to downsizing. The examiner noted depressed mood, anxiety, chronic sleep impairment and disturbance of motivation and mood. The Veteran reported having recurrent thoughts, avoiding conversations about Vietnam, a sense of a foreshortened future, irritability, feeling watchful, depressed mood, sleep disturbance and crying spells. In a May 2016 DBQ, a private physician summarized the Veteran’s level of occupational and social impairment with regard to all mental diagnoses as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgement, thinking and/or mood. The physician noted that the Veteran had been married to his second wife for 2 years but was not able to maintain healthy/intimate peer relationships due to his PTSD. This included social anxiety, being panicky, avoiding crowds including his family and peers, having a short temper in social situations, having difficulty communicating and getting along with others especially in work and social settings. It was noted that the Veteran had not worked since 2006 and the Veteran believed that he was let go from his previous job in 2006 due to in part from his problems from PTSD. The physician opined that the Veteran’s PTSD symptoms appeared to be severe enough to disable him from maintaining any form of gainful employment uninterrupted. The physician noted that the Veteran’s symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, flattened affect, difficulty in understanding complex commands, impaired abstract thinking, gross impairment in thought processes or communication, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances including work or a worklike setting, an inability to establish and maintain effective relationships, obsessive rituals which interfered with routine activities, impaired impulse control, neglect of personal appearance and an inability to perform daily activities. The private psychologist again noted that the Veteran was completely disabled and precluded from sustaining any form of substantial, gainful employment activity from the date of his claim for increase in October 2014. Under the circumstances of this case, and with resolution of all reasonable doubt in the Veteran’s favor, the Board concludes that a 70 percent disability rating, but no higher, for PTSD is warranted, effective October 27, 2014, which is the date his claim for an increased rating was received. For the period since October 27, 2014, the Board finds that the Veteran’s symptoms more nearly approximate a degree of occupational and social impairment consistent with deficiencies in most areas. Overall, the Veteran had a history of depression, anxiety, poor relationships, sleep problems, hypervigilance, suspiciousness and panic attacks. The May 2016 BBQ questionnaire from a private psychologist also indicated that the Veteran’s social and occupational impairment with regard to all mental diagnoses was best summarized as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. This description corresponds squarely with the schedular requirements for the assignment of a 70 percent disability rating for PTSD under the General Rating Formula. Accordingly, the evidence currently of record can be read as showing deficiencies in most of the areas listed under the criteria for a 70 percent rating. As a result, a rating of 70 percent is granted. However, after reviewing evidence of record as a whole, the Board finds that the assignment of a disability rating greater than 70 percent for the Veteran’s service-connected PTSD is not warranted. While treatment records demonstrate that the Veteran experienced significant occupational and social impairment, at no point did any examiner or treating physician find that the Veteran’s PTSD caused total occupational and social impairment, as is required for the assignment of a 100 percent rating. Notably, in the October 2016 BBQ questionnaire, the private psychologist opined the Veteran’s PTSD symptoms appeared to be severe enough to disable him from maintaining any form of gainful employment uninterrupted. However, the Board concludes that total social and occupational impairment is not demonstrated. Notably, the October 2016 specifically indicated that the Veteran was capable of managing his own financial affairs and continued to be married to and live with his second wife. As noted above, the maximum rating of 100 percent requires total occupational and social impairment. Private, VA treatment records, and VA examinations do not show a gross impairment in communication or thought processes, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation to time or place. Additionally, there are no reports of homicidal or suicidal ideation. Additionally, the treatment reports also noted that the Veteran had no current auditory or visual hallucinations and he was oriented to person, place and time while the May 2016 DBQ from a private psychologist again specifically described social and occupational impairment that corresponds squarely with the schedular requirements for the assignment of a 70 percent disability rating for PTSD under the General Rating Formula. Accordingly, in this case, the overall evidence of record does not reflect that the Veteran’s symptomatology is so severe as to merit an increased 100 disability rating. Thus, for all the foregoing reasons, the Board finds that a rating of 70 percent, but no higher, for PTSD is warranted. 2. Diabetes The Veteran filed a claim for an increased rating for his service-connected diabetes mellitus disability which was received by VA in October 2014. The Veteran has a current 20 percent disability rating for diabetes mellitus under Diagnostic Code 7913. See 38 C.F.R. § 4.119 (2017). Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet; a 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities; a 60 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated; and a 100 percent rating when the diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities), with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913. Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). Factual Background and Analysis The Veteran underwent a VA examination in March 2015. The examiner noted that the Veteran’s diabetes was managed by a restricted diet. However, the Veteran did not require regulation of activities as part of his medical management of his diabetes. He visited his diabetic care provider less than 2 times a month for episodes of ketoacidosis and hypoglycemia and needed no hospitalizations in the past 12 months. He did not have progressive unintentional weight loss or loss of strength attributable to his diabetes. The examiner also found that the Veteran’s diabetes mellitus did not impact his ability to work. Based on the evidence, the Board does not find that the Veteran is entitled to an evaluation in excess of the current 20 percent disability rating for his service-connected type II diabetes mellitus disability. As noted above, in order for a 40 percent disability rating to be awarded, the service-connected diabetes mellitus must require (1) insulin, (2) a restricted diet, and (3) regulation of activities. These criteria are conjunctive; all three elements must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991). The evidence of record indicates that the Veteran he has been prescribed oral hypoglycemic agents (metformin). Additionally, Veteran’s diabetes was managed by a restricted diet. Thus, two out of the three requirements for a higher disability evaluation are met. However, there is no evidence of restriction of activity. Regulation of activities is defined as “avoidance of strenuous occupational and recreational activities”. 38 C.F.R. § 4.119, Diagnostic Code 7913; see also Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). The objective medical evidence does not show that the Veteran’s diabetes mellitus results in any regulation of activities. On the contrary, the March 2015 VA examiner specifically noted that the Veteran did not require regulation of activities as part of medical management of his diabetes. The Board therefore finds that no basis exists for the assignment of a schedular rating in excess of the already assigned 20 percent for diabetes under Diagnostic Code 7913. Notably, while the Veteran has claimed that he has peripheral neuropathy and erectile dysfunction secondary to his diabetes mellitus, April 2014 and September 2014 VA examinations specifically found that the Veteran’s peripheral neuropathy and erectile dysfunction were not related to his service-connected diabetes mellitus. Additionally, in a separate March 2015 decision, the Board denied service connection for peripheral neuropathy and erectile dysfunction as secondary to his service-connected diabetes. Accordingly, separate evaluations for these disabilities are not warranted. As the preponderance of the evidence is against the claim for a rating in excess of 20 percent for a type II diabetes mellitus disability, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Earlier Effective Date Laws and Regulations A reasonably raised claim remains pending until there is either recognition of the substance of the claim in an RO decision from which a claimant could deduce that the claim was adjudicated or an explicit adjudication of a subsequent “claim” for the same disability. See Deshotel v. Nicholson, 457 F.3d 1258, 1261 (Fed. Cir. 2006) and Myers v. Principi, 16 Vet. App. 228, 229 (2002); 38 C.F.R. § 3.160(c). VA law and regulation provide that unless otherwise provided, the effective date of an award of increased evaluation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Regulations also provide that the effective date of an evaluation and award of compensation based on a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400(o) (1). The Board notes that the effective date of an award of increased compensation may, however, be established at the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application for an increased evaluation is received within one year from that date. 38 U.S.C. §5110(b) (2); 38 C.F.R. § 3.400(o) (2). Three possible dates may be assigned depending on the facts of a case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o)(1) ); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400(o)(2) ); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2) ). See Harper v. Brown, 10 Vet. App. 125, 126 (1997). Thus, determining an appropriate effective date for an increased rating under the effective date regulations involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible, (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o) (2). Under applicable laws and regulations, if an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was “factually ascertainable.” If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110(b) (2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400 (o) (1) (2); VAOPGCPREC 12-98 (1998). In making this determination the Board must consider all of the evidence, including that received prior to previous final decisions. Hazan v. Gober, 10 Vet. App. 511 (1997). VA recognizes formal and informal claims. A formal claim is one that has been filed in the form prescribed by VA. See 38 U.S.C. § 5101(a); 38 C.F.R. §3.151(a). An informal claim may be any communication or action, indicating an intent to apply for one or more benefits under VA law. Thomas v. Principi, 16 Vet. App. 197 (2002). See 38 C.F.R. §§ 3.1(p), 3.155(a) (in effect prior to March 24, 2015). An informal claim must be written, see Rodriguez v. West, 189 F. 3d. 1351 (Fed. Cir. 1999), and it must identify the benefit being sought. Brannon v. West, 12 Vet. App. 32, 34-5 (1998). All filings by a claimant must be construed based on a liberal reading. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (holding that “[i]n direct appeals, all filings must be read ‘in a liberal manner’ whether or not the veteran is represented”). Furthermore, according to 38 C.F.R. § 3.157(b) (in effect prior to March 24, 2015), once a claim for compensation has been allowed, receipt of a VA outpatient or hospital examination or admission to a VA hospital will be accepted as an informal claim for increased benefits. See Servello, 3 Vet. App. at 199. The date on the VA outpatient or hospital examination will be accepted as the date of claim. 38 C.F.R. § 3.157(b) (in effect prior to March 24, 2015). When the evidence is from a private physician, the date of receipt of such evidence will be accepted as the date of receipt of an informal claim. Id. at (b) (2). The Board notes that on March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As the appeal in this case was filed prior to that date, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015 will be applied in this case. 1. PTSD The Veteran contends that he should be entitled effective date earlier than October 27, 2014 for the award of a 70 percent rating for his PTSD disability. In a March 2006 rating decision, the RO granted service connection at an initial 30 percent disability rating, effective March 29, 2005 which was the date of the Veteran’s claim. On October 27, 2014, the Veteran filed a claim for an increased rating for his service-connected PTSD disability. In a March 2015 rating decision, the RO granted an increased 50 percent rating for PTSD, effective October 27, 2014, the date of the claim for an increased rating. As determined above, the Board has granted an increased 70 percent disability rating for PTSD, effective October 27, 2014. As such, under the law, the earliest the Veteran could be entitled to an effective date for his 70 percent evaluation would be October 27, 2013, which is one year prior to the date of the increased rating claim, if it is factually ascertainable that the increase in severity took place during that year. However, there is simply no evidence of record dated from October 2013 to October 2014 which would indicate an increase in severity of the Veteran’s PTSD disability occurred, such that an effective date earlier than October 27, 2014 would be warranted. There are voluminous VA records for this time period but this evidence does not show an increase in severity of the Veteran’s service connected PTSD disability until he filed a claim for an increased rating on October 27, 2014. As noted above, the increased rating from 30 to 50 percent for PTSD in the March 2015 rating decision was based on a March 2015 VA examination. Prior to October 27, 2014, there is no evidence that the Veteran’s PTSD warranted a rating in excess of 70 percent. As such, the Board finds that October 27, 2014, is the proper effective date for grant of increased rating for this disability. Accordingly, an effective date prior to October 27, 2014, (the date assigned by the RO), for a rating of 70 percent for a PTSD disability must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. 2. Diabetes Mellitus The Veteran contends that he should be entitled effective date earlier than January 21, 2011 for the award of a 20 percent rating for his diabetes mellitus disability. In an August 2007 rating decision, the RO granted service connection for diabetes mellitus at an initial 10 percent disability rating, effective May 11, 2007 which was the date of the Veteran’s claim. In March 2011, the Veteran filed a claim for an increased rating for his service-connected diabetes mellitus disability. In an October 2011 rating decision, the RO granted an increased 20 percent rating for diabetes mellitus, effective January 21, 2011, which was the date that it was factually ascertainable that the Veteran’s diabetes required oral hypoglycemic agents (Metformin) and a restricted diet. In this case, there are records of treatment for diabetes disability since the May 11, 2007 effective date of the initial 10 percent rating. However, with regard to showing a higher level of disability (20 percent or more), they do indicate any specific level of disability as there is no evidence prior to a January 21, 2011 VA treatment record that the Veteran required an oral hypoglycemic agent (Metformin) and a restricted diet. Notably, the January 21, 2011 VA treatment record is the first instance in the record where the Veteran was prescribed an oral hypoglycemic agent for treatment of his diabetes mellitus which along with a restricted diet warrants a 20 percent disability rating. As a result, an effective date before January 21, 2011, the date of the VA treatment record prescribing Metformin, is not warranted as there was no formal or informal claim for an increased rating prior to that time nor, significantly, is there any evidence of treatment showing an increase in severity prior to that time. As noted above, prior to January 21, 2011, there is no evidence that the Veteran’s diabetes mellitus required insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. Thus, prior to January 21, 2011, it is not factually ascertainable that the Veteran’s diabetes mellitus disability was 20 percent disabling or more. As such, the Board finds that January 21, 2011, is the proper effective date for grant of increased 20 percent rating for this disability. Accordingly, an effective date prior to January 21, 2011, for a rating of 20 percent for a diabetes mellitus disability must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. TDIU Laws and Regulations Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2017). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. 38 C.F.R. § 4.16(a) (2017). To meet the requirement of “one 60 percent disability” or “one 40 percent disability,” the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). Analysis In this case, the Veteran has argued that he has been unable to work a result of his service-connected PTSD disability. The Veteran is currently service-connected for PTSD at 70 percent disability rating; for diabetes mellitus at a 20 percent rating; for residuals of a gunshot wound to his left thigh at a 10 percent rating; and for a residuals gunshot wound to the left chest at a 10 percent rating. From October 27, 2014, the Veteran has a combined 80 percent evaluation. In addition, the Veteran has had at least one disability rated at 40 percent throughout this period. Therefore, the Veteran’s service-connected disabilities meet the rating percentage threshold for a TDIU. 38 C.F.R. § 4.16(a). Having met the objective criteria for a TDIU, the remaining question before the Board is whether the Veteran’s service-connected disabilities preclude him from securing or following substantially gainful employment. 38 C.F.R. § 3.321, 3.340, 3.341, 4.16. Here, the central inquiry is whether the Veteran’s service-connected disabilities, alone, are of sufficient severity to preclude her from obtaining and maintaining all forms of substantially gainful employment. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). After careful consideration and resolving reasonable doubt in his favor, the Board finds that the Veteran meets the requirements for a total disability evaluation based on individual unemployability due to service connected disorders. The record shows that the Veteran previously worked in maintenance and last worked full time in 2006. Notably, on the May 2016 DBQ, the private physician indicated that the Veteran the Veteran believed that he was let go from his previous job in 2006 due to in part from his problems from PTSD. The record demonstrates that the Veteran’s ability to work has been impacted by his service-connected psychiatric disability as he has notable occupational impairment from his psychiatric impairments as demonstrated by his current 70 percent disability rating for his service-connected PTSD. Notably, on the March 2016 DBQ, the private psychologist opined that the Veteran was completely disabled and precluded from sustaining any form of substantial, gainful employment activity from the date of his claim for increase in October 2014. Additionally, in an April 2017 correspondence, a vocational consultant opined that the Veteran was totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected PTSD, diabetes, left thigh gunshot wound and left chest gunshot wound. For these reasons, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran’s service-connected psychiatric disability renders him incapable of securing or maintaining substantially gainful employment. As a result, when affording the Veteran the benefit of the doubt, the Board finds that entitlement to TDIU is warranted. A remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In weighing the evidence, the Board finds that the evidence of record establishes that the Veteran is unable to obtain and maintain substantially gainful employment due to his service-connected PTSD disability. Accordingly, the Board finds that   entitlement to total disability evaluation based on individual unemployability due to service connected disorders is warranted. See 38 C.F.R. §§ 3.102, 4.16(a). MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James A. DeFrank, Counsel