Citation Nr: 20005698 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 19-16 986 DATE: January 23, 2020 REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1973 to February 1976. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2016 rating decision. Entitlement to a TDIU. Based on the cumulative evidence of record, the Board finds that a VA examination to clarify whether the effects of the Veteran’s service-connected disabilities, alone or in aggregate, on his ability to obtain and maintain substantially gainful employment consistent with his education and occupational experience during the time period from October 2012, is necessary to effectively adjudicate the TDIU claim on appeal. As such, the Board finds that a remand is warranted in order to afford the Veteran an additional VA examination. Littke v. Derwinski, 1 Vet. App. 90, 93 (1990) (holding that a remand may be required if the record before the Board contains insufficient medical information for evaluation purposes). Finally, evidence of record reflects that the Veteran has received VA medical treatment for his service-connected disabilities from the San Juan VA Medical Center (VAMC). As evidence of record only includes treatment records dated up to August 2019 from that facility, all pertinent VA treatment records should be obtained and associated with the record. See 38 U.S.C. § 5103A(c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following actions: 1. Obtain updated treatment records pertaining to the Veteran’s service-connected disabilities from San Juan VAMC for the time period from August 2019 to the present. 2. Thereafter, a VA medical examination must also be obtained to determine whether the functional effects of the Veteran’s service-connected disabilities, alone or acting in concert, preclude him from securing and following substantially gainful employment, consistent with his education and occupational expertise for the time period from October 2012. The electronic claims file must be made available to the examiner, and the examiner must specify in the report that the electronic claims file has been reviewed. The examiner must compile a full work and educational history. Following a thorough review of all pertinent medical records and the lay statements of record, the examiner must discuss the functional effects of the Veteran’s service-connected disabilities, acting alone or in concert, on his ability to obtain or retain employment consistent with his education and occupational experience during the time period from October 2012. This opinion must be provided without consideration of his nonservice-connected disabilities or age. To the extent possible, the VA examiner must address the degree of functional and industrial impairment due to each of the Veteran’s service-connected disabilities during the time period from October 2012. The examiner must furnish a full description of the effects of the service-connected disabilities upon the Veteran’s ordinary activities, which include employment. 38 C.F.R. § 4.10 (2019). This description may include an opinion on such questions as whether the Veteran’s service-connected disabilities precluded standing for extended periods, lifting more than a certain weight, sitting for eight hours a day, performing other specific tasks, etc. The examiner should discuss and reconcile the proffered medical opinion with the VA examination findings dated from 2012 to 2019, the January 2017 private physician statement, and VA and private treatment records dated from 2012 to the present. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on his claim. 38 C.F.R. § 3.655 (2019). 3. After completing the above actions and any other necessary development, the claim on appeal must be re-adjudicated, taking into consideration all relevant evidence associated with the evidence of record since the March 2019 SOC. If the benefit on appeal remains denied, a SSOC must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. D. Deane, Counsel 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.