Citation Nr: 20020006 Decision Date: 03/18/20 Archive Date: 03/18/20 DOCKET NO. 17-43 603 DATE: March 18, 2020 REMANDED Entitlement to a total disability rating based on individual unemployability by reason of a service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1971 to April 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to a TDIU is remanded. The Veteran claims that his service-connected disabilities prevent him from securing and following substantially gainful employment consistent with his educational and occupational experience. A review of the claims file reveals that there are several outstanding medical records which may support the Veteran’s claim. The Veteran submitted a February 2012 report from Dr. E.T. which indicate that the Veteran receives psychiatric treatment from Dr. J.S.A. in Franklin, Michigan. A July 2015 VA medical opinion indicates that the Veteran receives counseling from a Vet Center in Saginaw, Michigan and is prescribed psychiatric medication from Dr. L.B. There are no records from Dr. J.S.A. associated with the claims file. Similarly, while the claims file contains May 2011 and June 2012 letters from the Veteran’s counselor at the Saginaw Vet Center, no other records from the Veteran’s treatment have been associated with the claims file. Finally, the claims file indicates that attempts have been made to obtain the records from Dr. L.B., but those records have not yet been obtained and associated with the claims file. On remand, the RO should make attempts to obtain these outstanding records and associate them with the claims file. Additionally, in a December 2011 VA examination, the examiner reported that the Veteran worked at a golf course part time in the summer of 2010 and 2011. In a July 2015 VA examination, the examiner reported that the Veteran worked at Lapeer Country Club from 1989 until a few months prior to the July 2015 VA examination. In other statements, the Veteran has asserted that he had to quit a job at a golf club after two days due to his service-connected disabilities. On remand, the RO should attempt to clarify any part-time employment. The Board also notes that a December 2011 VA examination indicates that the Veteran receives social security benefits. It is unclear from the documents in the claims file whether the social security benefits that the Veteran receives from related to Social Security Disability Insurance (SSDI). On remand, the RO should seek to obtain any documents related to any application for SSDI filed by or on behalf of the Veteran. The Veteran has also provided an August 2015 document from the Michigan Unemployment Insurance Agency indicating that the Veteran sought unemployment benefits and was denied. On remand, the RO should seek to obtain all documents associated with the Veteran’s claim for unemployment insurance and associate those documents with the claims file. Finally, the Board finds that the medical evidence in the claims file is insufficient to determine whether the Veteran’s service-connected disabilities prevent him from securing and following substantially gainful employment consistent with his educational and occupational experience. The Board notes that the Veteran is service connected for post-traumatic stress disorder, diabetes mellitus, bilateral peripheral neuropathy of the lower extremities, and tinnitus. On remand, the Board should obtain an opinion from a qualified clinician regarding impact of the Veteran’s service-connected disabilities on his ability to secure and follow substantially gainful employment. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. J.S.A. and Dr. L.B. Make two requests for the authorized records from Dr. J.S.A. and Dr. L.B., unless it is clear after the first request that a second request would be futile. 2. Ask the Veteran to complete VA Form 21-8940 (Veteran’s Application for Increased Compensation Based on Unemployability) and specifically clarify any part-time employment over the years. 3. Ask the Veteran to complete a VA Form 21-4142 for the Vet Center in Saginaw, Michigan. After authorization is received, obtain any treatment records for the period from November 2010 to the Present. Document all requests for information as well as all responses in the claims file. 4. Make appropriate efforts to obtain records related to any claim made on or behalf of the Veteran for benefits from the Social Security Administration and associate those records with the claims file. If no such records exist, or they are otherwise unavailable, the claims file should be documented accordingly. 5. Make appropriate efforts to obtain records related to any claim made on or behalf of the Veteran for unemployment insurance benefits and associate those records with the claims file. If no such records exist, or they are otherwise unavailable, the claims file should be documented accordingly. 6. Obtain a VA examination opinion regarding the collective impact of the Veteran’s service-connected disabilities. The examiner(s) should elicit the Veteran’s complete employment history and educational background, and must comment on the impact of the service-connected disabilities, individually and in combination, on the Veteran’s ability to function in work-related tasks (e.g., sitting, standing, walking, bending, stooping, lifting, cognitive functioning, attendance, etc.). H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Boal, Associate 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.