Citation Nr: 21002432 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 15-35 560 DATE: January 13, 2021 REMANDED Entitlement to total disability based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from October 2001 to January 2005. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2013 notification letter by a Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In December 2019, the Board issued a decision denying entitlement to TDIU. The Veteran filed an appeal to the Court of Appeals of Veterans Claims (CAVC) contesting the Board's decision. In July 2020, CAVC vacated and remanded the Board's decision for compliance with the instruction in a Joint Motion for Remand (JMR). The parties of the JMR agreed the Board erred when it failed to adequately address the Veteran’s occupational history as contained in a 2015 VA examination. After vacating the Board’s decision, the case was remanded pursuant to 38 U.S.C. § 7252 (a) for readjudication and compliance with the instructions in the JMR. The Board finds that evidentiary development is still required before the claim on appeal can be adjudicated. 1. Entitlement to total disability based on individual unemployability is remanded. The Veteran contends that he is unable to obtain and maintain gainful employment due to the severity of his service-connected PTSD and sleep apnea. A total rating for compensation may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or, as a result of two or more service-connected disabilities, if at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran is service-connected for PTSD (70% from 1/14/2011); obstructive sleep apnea (50% from 4/19/2019); tinnitus (10% from 1/2/2015); intermittent seborrheic dermatitis (0% from 1/2/2005); and tinea versicolor with hyperpigmentation (0% from 1/2/2005 at 10% from 12/20/2013 and 0% from 10/20/20 ). He has a current combined service-connected disability rating of 90 percent, which meets the schedular criteria for a TDIU. In an August 2015 VA examination for his PTSD, in reference to his occupational history, the examiner noted that the Veteran reported that he was prescribed fluoxetine and hydroxyzine for his PTSD. The Veteran stated that he “doesn’t function normally with his prescription medication and makes mistakes on the medication.” The examiner however did not provide any information on the impact of the Veteran’s prescribed medication on his functional abilities. In the JMR the parties agreed that the Board failed to properly address the lay statements of the Veteran when deciding that a TDIU was not warranted. Thus, after consideration of the JMR, the Board finds that an addendum medical opinion is necessary to address the functional impact of the Veteran’s service- connected PTSD. Furthermore, additional and relevant evidence has been submitted since the most recent rating decision was issued in June 2020. This additional relevant evidence includes but is not limited to an updated VA Form 21-890 (Veteran’s Application for Increased Compensation Based on Unemployability), multiple VA examinations and CAPRI records. Given that this new evidence pertains to the claim and given that the Veteran has not waived consideration by the AOJ, the RO must consider this evidence and reevaluate the claim. Accordingly, the Board finds that a remand is necessary for AOJ consideration of the additional evidence and the issuance of an SSOC. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. Contact the Veteran to determine whether there are any additional relevant private treatment records and obtain any necessary authorizations to procure such records. 2. Obtain an addendum opinion from a psychiatrist or psychologist to determine the functional impact of the Veteran’s service- connected PTSD throughout the period on appeal. The examiner should comment on the effects of the Veteran’s PTSD on his ability to work throughout the period on appeal. The examiner should consider the evidence of the claims file and should directly address the Veteran’s assertion that he “doesn’t function normally with his prescription medication and makes mistakes on the medication.” The examiner should indicate how far back in time his service- connected PTSD has impacted his abilities. 3. Then, after conducting any other development deemed necessary, readjudicate the Veteran's claim with consideration of the evidence added to the electronic record since the last Rating Decision in June 2020. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental SSOC and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Nettey, 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.