Citation Nr: 20004641 Decision Date: 01/23/20 Archive Date: 01/21/20 DOCKET NO. 12-14 481 DATE: January 23, 2020 REMANDED Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to July 25, 2011, and on or after February 19, 2015, is remanded. Entitlement to an evaluation in excess of 70 percent for PTSD for the period from July 25, 2011, to February 19, 2015, is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1967 to November 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July 2008 and April 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In a June 2017 decision, the Board increased the evaluation for PTSD to 70 percent for the period from July 25, 2011, February 19, 2015, and denied an evaluation in excess of 50 percent during the remainder of the appeal period. The Board also denied entitlement to TDIU. The Veteran appealed the June 2017 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2019 memorandum decision, the Court vacated and remanded the Board decision. Upon review, the Board finds that additional development is needed prior to adjudication of the claims. Throughout the appeal period, the Veteran has received VA treatment for his service-connected PTSD, and it was noted in July 2017 that he was scheduled to returned to the outpatient clinic for a psychiatry follow-up appointment. However, the claims file does not contain any VA treatment records dated since August 2017. Therefore, the agency of original jurisdiction (AOJ) should obtain any outstanding medical records. Moreover, the Board finds that a VA examination is necessary to ascertain the current severity and manifestations of the Veteran’s service-connected PTSD. In addition, the Veteran is currently service connected for PTSD, tinnitus, and bilateral hearing loss, and his combined evaluation is 60 percent. The Veteran has asserted that his PTSD and bilateral hearing loss affect his ability to maintain employment. See e.g. July 2009 VA Form 21-8940. However, there is no medical opinion addressing the combined effects of his service-connected disabilities. Therefore, the Board finds such an opinion is needed. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for PTSD. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records, to include any records dated since August 2017. 2. The AOJ should request that the Veteran complete and return an updated VA Form 21-8940. 3. The AOJ should attempt to obtain a VA Form 21-4192 from any current or past employers. 4. After the foregoing development has been completed, the Veteran should be afforded a VA examination to determine the current severity and manifestations of his service-connected PTSD. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s PTSD under the General Rating Formula for Mental Disorders. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran’s PTSD. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completing the foregoing development, the AOJ should schedule the Veteran for a VA examination to determine the combined effects of his service-connected disabilities and any resulting impairment. The examiner should address how the Veteran’s service-connected disabilities alone result in functional impairment and comment on the Veteran’s ability to function in an occupational environment. If possible, he or she should also indicate if there is any form of employment that the Veteran could perform, and if so, what type. A written copy of the report should be associated with the electronic claims folder. 6. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.