Citation Nr: 18158418 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-62 389 DATE: December 14, 2018 REMANDED Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2002 to May 2013. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural history, the RO issued a March 2015 rating decision that, in pertinent part, increased the rating for the back disability from 10 percent to 40 percent and denied service connection for bilateral hearing loss. Subsequently, in a September 2015 rating decision, service connection for PTSD was granted and a 30 percent rating was assigned effective June 1, 2013. The Veteran filed a notice of disagreement (NOD) in April 2016 to the initial ratings assigned for the back disability and PTSD and to the denial of service connection for bilateral hearing loss. The RO acknowledged the NOD in a June 2016 letter but explained that the NOD was not timely as to the back and hearing loss disabilities because it was filed more than one year after the March 2015 rating decision. Thus, the only issue on appeal before the Board is the initial rating higher than 30 percent assigned for the PTSD. As will be discussed in further detail below, the record raises the issue of unemployability due to the Veteran's service-connected PTSD. See 38 C.F.R. §§ 3.340 , 4.16; Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Veteran waived a hearing before the Board in his December 2016 substantive appeal, via a VA Form 9. 1. Entitlement to an initial rating higher than 30 percent for the posttraumatic stress disorder (PTSD) is remanded. The Veteran was previously treated at VA for his service-connected PTSD. However, the most recent VA psychiatric treatment records associated with the claims file are dated in October 2014, more than four years ago. A remand is necessary to obtain any outstanding pertinent VA treatment records and associate them with the claims file. In addition, a remand is necessary to afford the Veteran an additional VA psychiatric examination to determine the nature and severity of his PTSD. The Veteran contends that the severity of his symptoms was not accurately reported in the June 2015 VA examination report. The Veteran believed the inaccuracies were due to the VA examiner not writing anything down during the examination and/or the VA examiner mixing up this Veteran’s case with another veteran’s case. The Board makes no determination on the adequacy of this VA examination at this time; however, a remand is necessary because the Veteran’s symptoms appear to have increased in severity since the June 2015 VA examination. The Veteran reported that he experiences extreme irritability, anxiety, constant depression, suicidal thoughts, anger, hostility toward others, difficulty with impulse control, feeling like a failure, alienating himself from others, avoiding crowds, hypervigilance, hyperarousal, mood swings several times daily, and neglect of his personal appearance and hygiene. The Veteran reported he has gained weight due to his depression. The Veteran reported having frequent panic attacks during a week, difficulty with his short and long-term memory, difficulty concentrating, difficulty with complex oral instructions, disturbance of motivation, conflict with his spouse, day and night terrors, worthlessness, hopelessness, and survivor’s guilt. See December 2016 VA Form 9. These symptoms, as reported by the Veteran, appear significantly worse than the severity of symptoms reflected in the June 2015 VA examination report. The fact that a VA examination is almost three and a half years old is not a valid basis, unto itself, to provide the Veteran with another VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). However, in this case, the Veteran has reported PTSD symptoms that are significantly worse than what is reflected in the most recent June 2015 VA examination; therefore, a new VA examination is required. Snuffer, 10 Vet. App. at 400. 2. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. The Veteran raised the issue of a TDIU in his December 2016 VA Form 9. Specifically, the Veteran reported that he had not worked in the preceding three years due to his increased irritability and “constant aggression” towards others. Further, the Veteran reported that he quit a job at Walmart shortly after discharge from service because of his “extreme issues with hostility, anxiety, anger and irritability to the point I wanted to get violent with other employees.” He reported similar symptoms when he attended college full-time. Thus, a remand is warranted to provide the Veteran with a VA Form 21-8940 Application for Increased Compensation Based on Unemployability, to provide appropriate VCAA notice, and to undertake the necessary development for a TDIU. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Provide the Veteran a VA Form 21-8940 and provide the necessary VCAA notice to inform the Veteran what evidence is required to substantiate entitlement to a TDIU. 3. Then, schedule the Veteran for an additional VA psychiatric examination to determine the nature and severity of the Veteran’s PTSD. All necessary testing and evaluations should be afforded to the Veteran. A thorough review of the claims file is required. All the Veteran’s contentions should be considered and reported. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Harper, Associate Counsel