Citation Nr: 18156664 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-63 448 DATE: December 11, 2018 REMANDED Entitlement to a higher initial rating for unspecified trauma and trauma related disorder, currently rated as 30 percent disabling, is remanded. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from March 1984 to April 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision of the Department of Veterans Affairs (VA). 1. Entitlement to a higher initial rating for unspecified trauma and trauma related disorder, currently rated as 30 percent disabling, is remanded. This claim is remanded to obtain outstanding medical records and a new medical examination. The Veteran contends that his current symptoms are worse than those encompassed by the 30 percent disability rating criteria; however, the most recent medical records on file are dated September 2016. The lack of recent medical records in the file does not allow the Board to accurately assess the present level of the Veteran’s disability or whether staged ratings are appropriate. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (stating that the present level of a disability is of primary importance where entitlement to compensation has already been established and an increase in the disability rating is at issue); Fenderson v. West, 12 Vet. App. 119 (1999) (requiring consideration of staged ratings in initial rating cases). Therefore, remand is appropriate to obtain treatment records from September 2016 to the present. Additionally, a new examination should be provided to assess the current severity of the Veteran’s disability. While the requirement for a contemporaneous examination does not require a new examination based upon the mere passage of time, an additional examination is appropriate when the claimant asserts that the severity of his disability has increased since the most recent VA examination. VAOPGCPREC 11-95 (Apr. 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Here, the last examination was provided in August 2016—nearly two and a half years ago. Given the date of the last examination and the Veteran’s contention that his condition is worse than reflected by the 30 percent rating criteria, another examination is appropriate. 2. Entitlement to a TDIU is remanded. The Veteran was previously denied entitlement to a TDIU in an April 2014 rating decision that he did not appeal. However, a TDIU claim is part and parcel of an increased rating claim if it is reasonably raised by the Veteran or the record. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran’s authorized representative raised the issue of unemployability in a November 2018 statement while the claim for a higher initial rating for unspecified trauma and trauma related disorder was pending review by the Board. Therefore, the Board finds that the issue of entitlement to a TDIU has been raised by the Veteran. Because the AOJ has not adjudicated the claim for a TDIU since it was raised and it is inextricably intertwined with the higher initial rating claim, the claim for a TDIU is remanded. On remand, the AOJ should obtain the Veteran’s federal records from the Social Security Administration (SSA) as the record indicates he was granted SSA disability benefits. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from September 2016 to the present. 2. Obtain the Veteran’s federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected unspecified trauma and trauma related disorder. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify all symptoms and social and occupational impairment due to his service-connected psychiatric disorder alone. 4. Thereafter, readjudicate the issue of entitlement to a higher initial rating for unspecified trauma and trauma related disorder, and following any indicated development, adjudicate the issue of entitlement to a   TDIU. If either benefit sought is not granted, issue a supplemental statement of the case, and afford the appropriate period to respond. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Kutrolli, Associate Counsel