Citation Nr: 20022486 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 16-01 565 DATE: April 1, 2020 REMANDED Entitlement to an initial rating higher than 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S Army from August 2003 to February 2004; August 2004 to February 2005, including service in Iraq, in support of Operation Iraqi Freedom; and from February to April 2009. He had additional service in the U.S. Army National Guard. This appeal arises from an October 2014 rating decision, granting service connection for PTSD and assigning an initial rating assignment of 50 percent. The Veteran appealed for a higher initial rating. In September 2018, the Board remanded a separate appeal for entitlement to service connection for an eye disorder to the AOJ for additional development and consideration. It appears this issue is not before the Board at this time. Also, in September 2018, the Board issued a decision denying the appeal for entitlement to an increased rating for PTSD. The Veteran then appealed this denial to the U.S. Court of Appeals for Veterans Claims (CAVC). During the pendency of the appeal, the AOJ further developed the increased rating claim for PTSD and issued another rating decision in July 2019, continuing to deny a rating in excess of 50 percent for PTSD. On appeal, CAVC issued an October 2019 non-precedential Memorandum Decision that vacated the Board’s prior September 2018 denial of an increased rating in excess of 50 percent for PTSD and remanded the matter to the Board. The CAVC decision also recognized that the Veteran has expressly raised a TDIU claim, per his November 2014 notice of disagreement (NOD), as due to his service-connected PTSD; and remanded the TDIU issue for further consideration to the Board. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Thus, the issues of entitlement to a higher initial rating than 50 percent for PTSD and a TDIU are presently before the Board. 1. Entitlement to an initial rating higher than 50 percent for PTSD 2. Entitlement to a TDIU The CAVC’s October 2019 decision, citing Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017), found the Board must engage in a “holistic analysis” of the Veteran’s PTSD symptoms and impairment, including consideration of occupational impairment and his ability to have and maintain relationships, such as marital and family relationships, and friendships. Recently, however, in June 2019, the AOJ arranged for a VA examination to reassess the severity of his service-connected PTSD. The Board observes the examination did not provide rationale for finding that the PTSD impairment resulted in “occupational and social impairment with reduced reliability and productivity,” as opposed to other more severe characterizations that would support ratings higher than the present 50 percent rating. The examiner’s remarks section also do not provide findings clarifying occupational impairment and his ability to have and maintain relationships as due to PTSD. When VA undertakes to examine a Veteran, VA is obligated to ensure that that examination is adequate. See Barr v. Nicholson, 21. Vet. App. 303 (2007). Moreover, the Veteran has expressly raised the TDIU issue in his November 2014 NOD and January 2016 substantive appeal (VA Form 9) as being due to his PTSD. So, the PTSD claim is inextricably intertwined with the TDIU claim, inasmuch as both concern the occupational impairment due to the service-connected PTSD disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). In this regard, the examiner recorded a confusing work history for the Veteran, which notes both that the Veteran is working as a bus mechanic for a school district and indicates his job situation is potentially threatened by missing work and interpersonal conflicts resulting from his PTSD symptoms. It is also not clear if the Veteran works full-time or part-time; therefore, the question of whether his job is tantamount to only “marginal employment” has been raised. On remand, it would be helpful for an examiner to provide medical comments on occupational impairment due to his PTSD. See id. Finally, the Veteran reported that he is receiving ongoing psychiatric treatment from Dr. H.J., a private psychiatrist, since 2014 to the present. See June 2019 VA examination report. It appears that Dr. H.J.’s psychiatric treatment records associated with the claims file are last dated in July 2014, such that more recent records are outstanding. On remand, the AOJ should ask the Veteran to identify such records, and if he does, attempt to obtain them. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical provider, VA or private, who has treated the Veteran for his mental health condition. After securing any necessary releases, request any relevant records identified that are not duplicates of those already contained in the claims file. Obtain any outstanding VA treatment records from Fayetteville, North Carolina VA Medical Center (VAMC), including dated since September 2018 to the present. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. Ask the Veteran to complete and submit a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability). Advise the Veteran that he should clarify his employment status and submit any additional relevant employment evidence that he may have. (Continued on the next page)   3. After associating any additional medical records with the claims file, then schedule the Veteran for an examination by an appropriate clinician, different than the June 2019 VA examiner, to determine the current severity of his service-connected PTSD. 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 any symptoms and social and occupational impairment due to his service-connected PTSD alone. A complete rationale should be provided for findings and opinions rendered. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Biswajit Chatterjee, 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.