Citation Nr: 21002505 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 16-62 437 DATE: January 13, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder with major depressive disorder and alcohol use disorder in remission (hereinafter PTSD) is denied. Entitlement to an initial rating in excess of 10 percent for hypertension is denied. Entitlement for a total disability rating based on individual unemployability (TDIU) is granted from April 16, 2014. Entitlement to special monthly compensation (SMC) at the housebound rate is granted from February 29, 2016. REMANDED Entitlement to service connection for a jaw disorder, to include temporomandibular joint disorder with bruxism and jaw fatigue claimed as a dental condition, to include as secondary to OSA and PTSD, is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The Veteran’s OSA had its onset during his active duty service. 2. The Veteran’s PTSD is not manifested by total social and occupational impairment. 3. At no time during the appeal has the Veteran’s hypertension more closely approximated diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. 4. From April 16, 2014, the Veteran’s PTSD has rendered him unable to secure or follow a substantially gainful occupation. 5. Beginning February 29, 2016, the Veteran has a single service-connected disability rated as total (PTSD with TDIU) and additional service-connected disability ratable at 60 percent (TBI) or more. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for obstructive sleep apnea are met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for an initial rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for an initial rating in excess of 10 percent for hypertension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, DC 7101. 4. The criteria for entitlement to a TDIU are met from April 16, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. 5. The criteria for SMC at the housebound rate are met from February 29, 2016. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from January 1998 to April 2004 and from June 2006 to June 2007, including service in Southwest Asia for which he was awarded the Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2014 and August 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board has recharacterized the Veteran’s claims, as reflected on the title page, to include consideration of all the related disorders reasonably raised by the record. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). Service Connection 1. Entitlement to service connection for OSA is granted. The Veteran asserts that his OSA either had its onset during active duty or is otherwise related to his active duty service, to include as secondary to his service-connected PTSD. See May 2015 VA Form 21-526EZ, March 2016 Notice of Disagreement (NOD). The Board agrees that direct service connection is warranted. Service connection may be established for a disability resulting from injury or disease incurred during active service. 38 U.S.C. § 1110. Generally, to establish service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Here, the Veteran has a current diagnosis of obstructive sleep apnea. See February 2015 VA sleep study. Therefore, element one of service connection is met. As to the second element, in-service incurrence of a disease or injury, the Veteran’s service treatment records (STRs) note a complaint of fatigue, still feeling tired after sleeping, headaches, and trouble breathing in his April 2007 Iraq Post-Deployment Health Assessment. Additionally, the Veteran reported to his July 2015 VA examiner that he began experiencing fatigue, daytime sleepiness, morning headaches, and loud snoring during sleep while in service from 2006 to 2007 and further endorsed that these symptoms persisted over the years until his February 2015 diagnosis. The Veteran is competent to report symptoms that come to him through his senses such as feeling tired, daytime somnolence, and snoring; and the Board has no reason to challenge the credibility of his reports, particularly since they are supported by his STRs. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Thus, element two of service connection is also met. Regarding element three, or nexus, there are two VA medical opinions of record offering evidence both in favor of and against the Veteran’s claim, though not inconsistent with each other. Against the claim is an August 2015 VA examiner’s opinion that concluded the Veteran’s OSA was not due to his PTSD. In favor of the claim is a July 2015 VA examiner’s opinion that the Veteran’s current OSA is a continuation of the symptoms that began during his active duty service and continued to the present. Thus, element three is also met, and direct service connection is established. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Increased Ratings 2. Entitlement to an initial rating in excess of 70 percent for PTSD is denied. The Veteran asserts that his PTSD warrants a higher initial rating, specifically a 70 percent rating, for the entire appeal period. See March 2015 Notice of Disagreement (NOD). The Board notes the Veteran was initially in receipt of a 50 percent rating effective March 12, 2013 that was increased to 70 percent throughout the appeal period in the November 2016 Statement of the Case. Though no rating decision was concurrently issued, the Veteran was provided with notification of this increase to 70 percent, effective March 12, 2013. See November 2016 notification letter. Although a higher rating has been assigned by the RO, the increased rating claim remains in appellate status as the maximum rating has not been assigned. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran’s PTSD is currently rated pursuant to 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula for Mental Disorders, a 70 percent rating is assigned when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational or social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a holistic analysis that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 100 percent. Initially, the Board notes that during the appeal period, the Veteran was granted service connection for a traumatic brain injury (TBI) effective February 29, 2016 and a separate rating of 70 percent was assigned, predominantly, for a moderate impairment of memory, attention, concentration, and executive functions. See December 2017 VA examination report, December 2017 rating decision. Specifically, the December 2017 VA examiner noted the Veteran’s long-term memory was intact, but that immediate short-term memory, focus, and concentration were symptoms of TBI. The December 2017 VA examiner also attributed subjective symptoms that mildly interfered with the Veteran’s social and occupational engagement to TBI, including insomnia, headaches (both migraine and non-migraine), sensitivity to sound and light, and some balance or equilibrium problems. Finally, the December 2017 examiner found that anger, irritability, and impulsivity mildly interfered with the Veteran’s work-place interaction and social interaction due to his TBI. Thus, the Board is precluded from considering these symptoms when assigning a rating to his separately compensated PTSD. 38 C.F.R. § 4.14; Mittleider v. West, 11 Vet. App. 181 (1998). In this regard, the Veteran submitted to VA psychological examinations in July 2014 and March 2017 and provided a VA-completed examination report in October 2014 (received March 2015). The July 2014 VA examiner concluded the Veteran’s PTSD was affecting his social and occupational impairment by reducing his reliability and productivity due to symptoms such as: depressed mood, anxiety. panic attacks occurring weekly or less often, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Additionally, the July 2014 examiner noted that on the day of the examination the Veteran denied suicidal ideation, but originally sought treatment with VA treatment providers in 2013 due to suicidal ideation. The Veteran also reported recurrent nightmares, intense prolonged psychological distress, psychological reactions to reminders of his in-service combat experiences, hypervigilance, exaggerated startle response, feelings of isolation, and an inability to experience positive emotions. The October 2014 VA examination report, completed by the Veteran’s treating PTSD clinician, again concluded the Veteran’s PTSD was productive of a reduced reliability and productivity due to symptoms such as: depressed mood, anxiety, flattened affect, difficulty in adapting to stressful circumstances, and suicidal ideation. The October 2014 examiner found the Veteran demonstrated chronic maladaptive thoughts related to survivors’ guilt and worthlessness and noted the Veteran’s report that he had been unable to maintain employment due to his PTSD symptoms, switching jobs three times in one year. The Veteran again endorsed experiencing nightmares, engaging in social isolation, feelings of detachment from others, a sense of foreshortened future, hypervigilance, and significant distress. The March 2017 VA examiner concluded the Veteran’s PTSD was presenting as occupational and social impairment with reduced reliability and productivity due to symptoms such as: depressed mood, anxiety, and a difficulty in adapting to stressful circumstances (including work or a worklike setting). The March 2017 VA examiner went on to express concern regarding the Veteran’s frequently varying mood symptoms, concluding they were having a moderate impact on his day to day functioning and were worsening due to his inability to maintain employment. The Board notes that the March 2017 VA examiner concluded the Veteran did not have a TBI, as one was not documented in his STRs and, therefore, all of the reported cognitive and memory symptoms were more appropriately addressed under the penumbra of his PTSD diagnosis. However, the Veteran has since been diagnosed with a TBI, is service-connected and separately rated for a TBI and has competently and credibly reported blast exposures and a helicopter crash. 38 U.S.C. § 1154(b). See also DD Form 214, December 2017 VA examination report. Thus, to the extent the March 2017 examiner opined the Veteran does not have a TBI, the Board finds the examiner’s opinion inadequate in this limited regard. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). In addition to the VA examinations of record, the Veteran has consistently and throughout the appeal period reported that he experiences suicidal ideation that is intermittently accompanied by planning. See January 2014 VA treatment records, February 2014 VA Form 21-4138, February 2014 private treatment records, October 2014 examination report, May 2015 VA Form 21-8940, September 2015 Veteran lay statement, January and March 2017 VA treatment records, March 2020 Board Hearing Transcript at 4. The Veteran has also reported experiencing nightmares (including becoming physically aggressive during nightmares), intense guilt and sorrow regarding his knowledge of Iraqis that were killed as a result of their collaboration with him, depression, anxiety, avoidance behaviors, panic attacks (including one inside of an airport), anhedonia, being easily overwhelmed, fight-or-flight anxiety attacks, intermittently illogical or irrelevant language patterns, and inconsistent situational awareness (overreaction). See February 2014 VA Form 21-4138; February 2014 private treatment records; March 2015 NOD; May 2015 VA Form 21-8940; July 2015 lay statement from A.M.; March 2012, February 2017 Veteran lay statement, January 2017 VA treatment records, April 2020 Board Hearing Transcript at 7, 9 -10. The Board acknowledges that the Veteran has additionally reported many other symptoms such as unprovoked irritability, anger (getting into fights with neighbors), and impulsivity (punching appliances) that have been attributed to his TBI and, as previously noted, cannot be simultaneously attributed to his PTSD. 38 C.F.R. § 4.14. Regarding occupational impairment, the Veteran has consistently reported difficulty maintaining stable employment. See February 2014 VA Form 21-4138, February 2014 private treatment records, May 2015 VA Form 21-8940. The Veteran concedes that he most often quits his jobs and is not fired. See July 2014 VA examination report. At the October 2014 VA examination, the Veteran reported to the examiner that he was on his third job in the past year and that he left the first two due to an increase in his PTSD symptoms and was subsequently employed selling cars. In May 2015, the Veteran reported that his auto-sales job ended after two and a half months when he found himself getting angry with customers, was suspicious of co-workers, began considering suicide, and generally felt over-whelmed. See May 2015 VA Form 21-8940. The Veteran has had to rely on the generosity of family members in order to remain in his home and pay for his utilities. See September 2015 Veteran lay statement. Additionally, he reports applying for but not obtaining employment as a cashier at Barnes and Noble, a driver of a snow cone truck, a forklift operator, and a concessions associate at a local sporting and events arena. Id. The Veteran likewise reports that at times, his PTSD symptoms are so severe that he cannot bring himself to leave his home up to 10 days per month and sometimes remains in bed for up to 20 hours at a time. See March 2016 Veteran lay statement, November 2016 VA treatment records. The Board finds this evidence does not equate to total occupational impairment, but supports a TDIU from 2014, as detailed below. As to social impairment, while the Veteran reports socially isolating, feelings of estrangement, and being easily overwhelmed with any work-like situation, the Board does not find that his social impairment is consistent with symptomatology contemplated by a 100 percent or total rating. In this regard, the Veteran has reliably reported that he maintains positive relationships with co-workers and supervisors even after leaving a job, he has frequently traveled both domestically and internationally volunteering with Veteran-centric non-profit organizations, and has more recently expressed a desire to travel internationally on landmine removal mission trips. See July 2014 VA examination report; September 2016, October 2016, and November 2016 VA treatment records. At the March 2017 VA examination, the Veteran reported a strained relationship with his parents but also noted that he sees them 3 to 4 times per week and talks with them daily. The Veteran also reported healthy relationships with his brothers, sisters, nieces and nephews, and an especially good relationship with one of his cousins. Id. The Veteran endorsed having other long-term friends, enjoying spending time with friends locally, and maintaining healthy relationships with past romantic partners. Id. The March 2017 VA examiner concluded the Veteran was functioning quite well and had meaningful interpersonal relationships. Given this evidence, the Board does not find the Veteran’s social impairment to approximate greater than that associated with a reduced reliability, consistent with the VA examinations of record. Likewise, the Veteran has denied experiencing any auditory or visual hallucinations or delusional thinking and has consistently been noted as having fair to good insight and judgment. See December 2015, October 2016, November 2016 VA treatment records. The Veteran has appeared well-groomed and appropriately dressed at all of his VA examinations and while participating in VA treatment. See, generally, November 2012 to April 2017 VA treatment records. The Board has also considered the Veteran’s voluntary admission into domiciliary care for his PTSD from June 25, 2019 to July 16, 2019. The attending medical doctor noted the Veteran completed the program successfully, participated in his treatment plan and group sessions, and was discharged home in stable condition without any suicidal or homicidal ideation. See July 2019 VA treatment records. Generally, domiciliary care does not constitute hospitalization pursuant to 38 C.F.R. § 4.29 and the Veteran has not asserted such. 38 C.F.R. § 17.30(b). Considering the above evidence, the Board finds that throughout the appeal period the Veteran’s PTSD has more closely approximated a 70 percent rating, but no higher, for occupational and social impairment with deficiencies in most areas . See Bankhead, supra. The Board notes that the evidence of record shows the Veteran has reported additional symptomatology not enumerated in the rating criteria, including hypervigilance and intrusive thoughts. However, the symptoms listed in the rating criteria are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. These additional symptoms are not seen as effecting more than a reduction in reliability and productivity. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board finds that the evidence of record does not support a finding that the Veteran has exhibited the level of cognitive, occupational and social impairment that would render him totally occupationally and socially impaired as a result of the type of symptoms listed in the general rating schedule or symptoms of a similar degree. As such, the preponderance of the evidence shows that the Veteran's psychiatric symptomatology does not more closely approximate the criteria for a 100 percent disability rating under the general rating schedule for psychiatric disorders, and the issue on appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Entitlement to an initial rating in excess of 10 percent for hypertension is denied. The Veteran is in receipt of an initial rating of 10 percent for his hypertension and asserts that a higher rating is warranted throughout the appeal period. See March 2015 NOD. Under DC 7101, a 10 percent rating is warranted for diastolic pressure predominately 100 or more or systolic pressure predominately 160 or more. A 10 percent rating is also the minimum rating for a veteran with a history of diastolic pressure predominately 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominately 110 or more or systolic pressure predominately 200 or more. Higher ratings are warranted for greater diastolic pressure. 38 C.F.R. § 4.104, DC 7101. The Veteran has required medication for control of his hypertension throughout the appeal. See July 2014 VA examination report. However, his blood pressure readings during the period on appeal do not meet or more closely approximate the criteria for a rating in excess of 10 percent. In this regard, the Veteran’s systolic pressure has remained under 160 and his diastolic pressure has remained under 100 throughout the period on appeal and is well-controlled by medication. See February 2013, March 2014, December 2015, January 2016, March 2016, June 2016, July 2016, October 2016, December 2016 VA treatment records; July 2014 VA examination report. Critically, the Veteran testified that he was aware that his blood pressure has remained stable and “normal” since he began medication. See April 2020 Board Hearing Transcript at 21-22. Thus, as the Veteran has not more closely approximated the criteria for a higher rating for hypertension, a rating in excess of 10 percent is denied. 4. Entitlement to a TDIU is granted from April 16, 2014. The Veteran asserts that he is entitled to TDIU benefits. The Board agrees. Entitlement to a TDIU has been raised by the record and is a component of the instant appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009); see also February 2014 VA Form 21-4138. VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing or following “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran’s master’s degree in education and his part-time work as a tutor). TDIU can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). Here, the Veteran is currently in receipt of a single disability rated as 70 percent (PTSD) disabling from March 12, 2013, the effective date of service connection. Thus, throughout the period on appeal, he has met the minimum percentage requirements for a TDIU. 38 C.F.R. § 4.16(a). The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran’s ability to secure or follow substantially gainful employment, including factors such as the veteran’s history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The evidence demonstrates the Veteran last worked full-time as a project leader from September 2010 to August 2011, earning approximately $120,000.00 per year. See May 2015 VA Form 21-8940. Thereafter, the Veteran was predominantly employed part-time until he became totally unemployed in the Spring of 2015. Id. See also April 2020 Board Hearing Transcript at 34. Regarding 2013, the Veteran reported working part time from February 2013 to June 2013 with the YMCA earning $400.00 per month and from June 2013 to December 2013 with a charitable organization earning $6,000.00 per month. Thus, in 2013 the Veteran earned in excess of the poverty threshold for a single individual. See United States Census Bureau, Poverty Thresholds, 2013-2015, www.census.gov (last accessed January 13, 2021). In 2014, the Veteran reported working from February 2014 to May 2014 as a car salesman earning $3,000.00 per month and from July 2014 to May 2015 with a policy institute earning $3,000 per month and accordingly also exceeded the policy threshold in 2014. Id. In 2015, the Veteran reported earning $3,000.00 a month through April when he was no longer able to maintain even part-time employment. See April 2020 Board Hearing Transcript at 34-35. Thus, regarding the economic component, the questions for the Board are whether the Veteran’s PTSD symptoms were precluding employment and, if so, whether any of the Veteran’s earnings from 2013 to 2015 represent income derived from employment within a “protected environment” thus qualifying as marginal employment. 38 C.F.R. § 4.16(a). The Veteran does not assert, and the evidence does not otherwise demonstrate, that his earlier part-time and full-time employment with the YMCA, the Veteran-centric charitable organization, or his work as a car salesman were constrained due to his PTSD symptoms. The Veteran testified that he left the YMCA when a friend gave him a 6-month job at a veteran-centric charitable organization helping to promote a software application. See April 2020 Board Hearing Transcript at 31-32. Once this job was considered complete, he then sought employment as a car salesman. Id at 32-33. The Board finds that the Veteran’s PTSD symptoms did not contribute to an inability to obtain or maintain gainful employment in these roles. See April 2020 Board Hearing Transcript at 33-34. However, the Veteran’s PTSD symptoms worsened while the Veteran was employed as a car salesman. See March 2017 VA examination report. In fact, the Veteran reported that he left his position as a car salesman because he was concerned that his increasing anger at customers and becoming suspicious of his co-workers would lead to outbursts. Id. Thus, the Board concludes that prior to April 16, 2014, the Veteran’s PTSD was not preventing him from securing or following substantially gainful employment and also finds that the Veteran’s increasing PTSD symptoms that caused him to leave his position as a car salesman represents the point at which the Veteran’s PTSD progressed to appreciably impairing his ability to maintain employment. 38 C.F.R. § 4.16(a). In this regard, the Veteran testified that when he left his position as a car salesman due to his increasing PTSD symptoms, he sought out and subsequently obtained a position working for a friend who accommodated the Veteran’s limitations caused by his service-connected PTSD. See May 2015 VA Form 21-8940, May 2015 VA Form 21-4192, April 2020 Board Hearing Transcript at 34. He further testified that this work did not have any productivity requirements, no real responsibilities, that he could work when he was able, and that it provided a steady paycheck despite the lack of structure or accountability. Id. As the Veteran was provided with special accommodations due to his service-connected PTSD symptoms that likely would not be tolerated by any other reasonable employer, the Board finds that the Veteran’s position from July 2014 to May 2015, while in excess of poverty thresholds, is tantamount to work in a protected environment. 38 C.F.R. § 4.16(a). Accordingly, prior to April 16, 2014 (the first day after he left the car sales job), his employment does not satisfy the economic component required for the grant of a TDIU as his PTSD symptoms were not preventing him from securing or following a substantially gainful occupation. See Ray, supra. Thus, any grant of a TDIU prior to April 16, 2014 is precluded. Regarding the non-economic component, the Veteran has a bachelor’s degree in comparative religion and last worked in a paid part-time position as a policy advisor in 2015. An April 2020 VA psychologist noted the Veteran’s bachelor’s degree in comparative religion was outdated and determined the Veteran had a serious employment handicap based on his vocational impediments stemming from his service-connected conditions, lack of education and/or training for suitable employment, history of alcohol abuse, and record of a psychiatric condition. The examiner concluded that the Veteran’s mental health issues precluded the Veteran from working in certain types of employment that contain demands/tasks that would be incompatible with the disabilities and approved him for vocational rehabilitation. Given these findings, the Board finds that the overall severity of the Veteran’s psychiatric symptoms described above preclude substantially gainful employment, since April 16, 2014, when he left his job selling cars due to his worsening PTSD symptoms and subsequently obtained employment in a protected environment. Hence, entitlement to a TDIU is warranted from April 16, 2014, the first day after the date he quit working as a car salesman. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 3.400. 5. Entitlement to SMC is granted from February 29, 2016. VA has a “well-established” duty to maximize a claimant’s benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC ”benefits are to be accorded when a Veteran becomes eligible without need for a separate claim” and remanding, pursuant to VA’s duty to maximize benefits, for VA to determine whether the Veteran’s posttraumatic stress disorder, rated 70 percent disabling, would entitle him to a TDIU and, therefore, to SMC). Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350(i). The Veteran is currently in receipt of a TDIU based solely on his PTSD and has additional service-connected disabilities independently ratable at 60 percent (TBI). See 38 C.F.R. § 4.16(a)(4). Thus, SMC at the housebound rate is warranted from February 29, 2016. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). Prior to February 29, 2016, the Veteran did not have a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability (TDIU based solely on his PTSD). Further, there is no evidence that the Veteran is permanently housebound by reason of service-connected disability or disabilities. Therefore, he is not entitled to SMC at the housebound rate prior to February 29, 2016. REASONS FOR REMAND 6. Entitlement to service connection for a jaw disorder (claimed as tooth disorder), to include temporomandibular joint disorder with bruxism and jaw fatigue, to include as due to OSA and PTSD, is remanded. The Veteran asserts that he is experiencing jaw fatigue and soreness accompanied by bruxism that is due to his PTSD or his now service-connected OSA. Here, the Veteran is service-connected for both PTSD and OSA and his May 2020 private dental records indicate the Veteran is experiencing jaw fatigue and that he wears a Biteguard due to his OSA to help lessen jaw fatigue, damage to dentition, and frequency of migraine headaches. While the May 2020 private dental records relate jaw fatigue and the need for a Biteguard to the Veteran’s OSA, no medical rationale is provided. Accordingly, the Board finds that the low standard detailed in McLendon is met and a VA examination and medical nexus opinion is warranted and should be obtained on remand. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 7. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran asserts that he has bilateral hearing loss that is due to his combat service in Southwest Asia. In this regard, the Veteran submitted to a VA examination in July 2014. The July 2014 examiner opined that the Veteran’s hearing loss was due to his combat service; however, at that time the Veteran did not have hearing loss for VA purposes pursuant to 38 C.F.R. § 3.385. At the April 2020 Board Hearing, the Veteran testified that his hearing loss had progressed since his last and only examination in July 2014. Thus, as the Veteran has verified combat service, there exists a positive nexus opinion between any hearing loss and the Veteran’s combat service, and the Veteran has testified that his hearing loss has worsened, the Board finds an updated examination is required on remand. Any outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, secure any outstanding private treatment records. 3. Then schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed disorders of the jaw. The entire claims file should be made available to and reviewed by the examiner. All findings should be reported in detail. (a.) Identify all current jaw disorders, to include any diagnosis to account for jaw pain, fatigue, and bruxism. If no diagnosis is rendered, please rectify your findings with those of the Veteran’s private dental provider (see May 2020 dental records). (b.) For each disorder diagnosed in part (a.), the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that such disorder: 1. is proximately due to the Veteran’s service-connected PTSD and/or OSA; or 2. has been aggravated (worsened) his service-connected disabilities to include PTSD and OSA. In addressing secondary service connection, please note that the service-connected disability (PTSD and OSA) need not be diagnosed or service-connected at the time the secondary (any diagnosed disorder of the jaw) disability is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. A complete rationale shall be given for all opinions and conclusions expressed. 4. Then schedule the Veteran for a VA audiological examination to determine if the Veteran has hearing loss for VA purposes. No additional medical opinion is required, as the July 2014 VA examiner concluded that any hearing loss the Veteran has is due to his combat service in Southwest Asia. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Rouse, 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.