Citation Nr: 21071276 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 19-17 732 DATE: November 30, 2021 REMANDED Entitlement to an increased rating for posttraumatic stress disorder, currently evaluated at 30 percent, is remanded. Entitlement to a Total Disability rating based on Individual Unemployability is remanded. REASONS FOR REMAND The Veteran served in the United States Army from March 1969 to January 1971, including tours of duty in the Republic of Vietnam. His awards include the Army Commendation Medal with "V" device for Valor and 2 Oak Leaf Clusters, the Bronze Star Medal, Combat Infantryman Badge, the Air Medal, the Vietnam Service Medal with 2 Bronze Service Stars, and the Republic of Vietnam Campaign Medal. Service records reflect that the Veteran served as a sniper in the 22d Infantry and was instrumental in successful combat missions in support of American operations. Following an April 3, 2018 Ratings Decision that rated the Veteran at 30 percent for service-connected post-traumatic stress disorder (PTSD), the Veteran filed a Notice of Disagreement (NOD) on March 1, 2019 that included a five-page hand-written statement supporting his claim. Following the VA's Statement of the Case, the Veteran filed a Form 9 appeal on June 14, 2019 that included two additional hand-written pages of information in support of his claim. The Agency of Original Jurisdiction (AOJ) then certified the appeal to the Board. 1. Rating for Post-Traumatic Stress Disorder is remanded. The Veteran completed a VA examination in March 2018 that resulted in the 30 percent rating for PTSD. Three and a half years have passed since that examination, and the Veteran's statements, along with the statements submitted by the Veteran's representative, suggest that his symptoms have worsened in the interim. In his NOD statement, the Veteran reported, "I'm not showing much improvement." In his Form 9 statement, the Veteran reported, "I am always depressed and take two anti-depressants to function as best I can." The Form 9 statement included descriptions of disconnected family relations and persistent nightmares and sleeping difficulty. The brief submitted by the Veteran's representative noted the Veteran's "condition is worsening since the Veteran has retired." In addition to the need for an updated examination, the Veteran and his representative have indicated that there are likely treatment records available that are not currently associated with the claims file. In his NOD statement, the Veteran reported, "I am seeing a VA therapist weekly" and "I have seen three VA therapists and was referred by VA to a private therapist for a non-VA diagnosis." The VA mental health treatment records in the file span from February 2017 to January 2018. There are no records currently in the claims file from any non-VA providers. Evidence reflecting the current status of the Veteran's PTSD is necessary to determine whether this Veteran's condition more nearly approximates a higher rating criteria. 2. Total Disability due to Individual Unemployability is remanded. The information submitted by the Veteran raises a potential claim for Total Disability rating based on Individual Unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447 (2009). In his NOD statement, the Veteran reported, "I could not continue my job due to my quick anger, lack of trust, sleepless nights, and nightmares. If not for that, I could still be working." In his Form 9 statement, the Veteran reported, "With respect to the effect on my employment, I lived with constant stress, I couldn't deal with public situation (sic) anymore. Knowing my company retirement would only last 7 years and 5 years are already gone. I was not required to retire but with my mental state, my depression, trouble remembering important things, and anger issues, I had to get out." The Veteran's representative further noted that the Veteran may have been employed in a sheltered situation prior to his retirement due to the fact that he worked in a family business selling insurance with his father. Based on this information, the AOJ must consider whether the Veteran is entitled to TDIU and it has not done so to date. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to assess the current manifestation and presentation of the Veteran's PTSD. The examiner must review the Veteran's claims file prior to examination. 2. Request that the Veteran submit VA Form 21-4142 for all private providers from whom he has received mental health treatment or other therapy related to his PTSD. 3. Obtain all non-VA treatment records from providers identified by the Veteran. Notify the Veteran if the authorized records cannot be located. 4. Obtain all records of VA mental health treatment and other therapy associated with his PTSD. 5. After undertaking any other development deemed appropriate as a result of the above-requested development, readjudicate the issue of PTSD rating on appeal. 6. Conduct any development deemed necessary and adjudicate the Veteran's entitlement to TDIU. If the Veteran does not meet the schedular criteria for TDIU consideration under 38 C.F.R. § 4.16(a), determine whether referral to the Director, Compensation Service is required under 38 C.F.R. § 4.16(b). 7. If any benefit sought is not granted, then provide the Veteran and his representative with a Supplemental Statement of the Case and afford an opportunity to respond. Then return the case to the Board for further review if otherwise in order. RAY BARTO SLABBEKORN, JR. Veterans Law Judge Board of Veterans' Appeals Slabbekorn Jr, Ray 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.