Citation Nr: 21006309 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 18-54 251 DATE: February 3, 2021 ORDER A rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. A rating in excess of 60 percent for ischemic heart disease prior to February 9, 2016, and in excess of 30 percent thereafter, is denied. A rating in excess of 10 percent for a shell fragment wound left suborbital area with retained foreign body scar is denied. An effective date earlier than August 19, 2013, for the award of service connection for ischemic heart disease is denied. The claim of entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only is dismissed. A total disability rating for individual unemployability due to service-connected disabilities (TDIU) beginning April 12, 2012, is granted. Special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s) beginning August 19, 2013, is granted. FINDINGS OF FACT 1. The Veteran’s PTSD most closely approximated occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and suicidal ideation. 2. The Veteran’s ischemic heart disease resulted in workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope prior to February 9, 2016, and a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope thereafter. 3. The Veteran’s left suborbital area scar resulted in mild irritation with itching approximating the disability of one painful scar. 4. The Veteran first filed a service connection claim for ischemic heart disease on August 19, 2013. 5. The appellant’s claimed benefit of financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, is not a periodic monthly benefit, but rather a one-time lump sum payment. 6. Beginning April 12, 2012, the Veteran was unable to secure or follow a substantially gainful occupation due to his service-connected PTSD. 7. Beginning August 19, 2013, the Veteran’s service-connected disabilities, separate and distinct from PTSD and involving different anatomical segments or bodily systems, were independently ratable at 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for a 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 9411. 2. The criteria for a rating in excess of 60 percent for ischemic heart disease prior to February 9, 2016, and in excess of 30 percent thereafter, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. 3. The criteria for a rating in excess of 10 percent for a shell fragment wound left suborbital area with retained foreign body scar are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800, 7804. 4. There is no legal basis for an effective date earlier than August 19, 2013, for the award of service connection for ischemic heart disease. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. 5. The appellant is ineligible to receive financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, as a substitute claimant. 38 U.S.C. §§ 5121(a), 5121A; 38 C.F.R. §§ 3.1000(a), 3.1010(a). 6. The criteria for a TDIU beginning April 12, 2012, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. 7. The criteria for SMC pursuant to 38 U.S.C. § 1114(s) beginning August 19, 2013, are met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1967 to December 1969. He died in January 2019. The appellant is the Veteran’s widow, who has been recognized as a substitute claimant in the place of the Veteran pursuant to 38 U.S.C. § 5121A. This appeal is before the Board of Veterans’ Appeals (Board) from a June 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office. While the Veteran initially appealed the issue of entitlement to a TDIU to the Board, in a subsequent November 2020 rating decision, the agency of original jurisdiction (AOJ) granted a TDIU effective August 19, 2013. However, the Veteran originally filed a TDIU claim on April 12, 2012, which was initially denied in an August 2013 rating decision, along with an increased rating claim for PTSD. The Veteran also, prior to that rating decision, in August 2013, filed a new claim for the specifically identified disability of ischemic heart disease, submitted in a statement in support of his TDIU claim. Following the August 2013 denial of his TDIU claim, in August 2013, he further submitted evidence in support of his heart disease claim. Under these circumstances, the Board considers the later evidence submitted as having been filed in connection with the pending, April 12, 2012, TDIU claim. See 38 C.F.R. § 3.156(b). The issue of entitlement to a TDIU prior to August 19, 2013, is therefore still on appeal and will be considered by the Board. Moreover, in light of the Board’s findings regarding the TDIU claim, discussed below, and the Veteran’s additional service-connected disabilities and their ratings beginning August 19, 2013, the issue of SMC pursuant to 38 U.S.C. § 1114(s) beginning August 19, 2013, is reasonably raised by the record and addressed below. See Buie v. Shinseki, 24 Vet. App. 242 (2010); Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Increased Rating Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Reasonable doubt regarding any point will be resolved in favor of the claimant. 38 U.S.C. § 5107. 1. A rating in excess of 70 percent for PTSD is denied. The Veteran’s PTSD is rated under Diagnostic Code (DC) 9411, 38 C.F.R. § 4.130. Under DC 9411, the following applies: A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment, with reduced reliability and productivity, due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more frequently than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 rating is warranted when there is 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 worklike setting); and an inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and 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; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). The record in this case reflects that the Veteran’s PTSD most closely approximated occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and suicidal ideation. The Veteran underwent VA examinations of his PTSD in August 2013, September 2015, and January 2016. On each such examination, the Veteran was determined to have had, at most, an impairment level of occupational and social impairment with reduced reliability and productivity, which is the level of impairment contemplated by a rating of 50 percent under DC 9411. On these examinations, symptoms of anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and suicidal ideation were noted. These VA examination reports are consistent with the contemporaneous VA treatment records, which reflect some suicidal ideation, depression, anxiety, irritability, intrusive thoughts, and poor motivation, sleep, and concentration. The Board notes that, on October 2018 VA examination, the examiner assessed “total occupational and social impairment.” However, the only explanation for the level of functional impairment given by the examiner was that the Veteran exhibited “mild limitations in the areas of remember or applying information”; “noticeable limitations in relating to and working with supervisors, co-workers, and others; “mild limitations in the ability to concentrate, persist, or maintain pace”; and “noticeable limitations in trying to adapt and manage oneself.” It was not explained how such functional limitations amounted to a level of “total” occupational and social impairment. Moreover, even given this assessment, the symptoms attributed to the Veteran’s PTSD were not of the nature or severity of those contemplated in a 100 percent rating. Rather, they were consistent with a 70 percent rating or less: depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and suicidal ideation. The Board notes statements dated in June and October 2012, August 2013, and October 2016 from the Veteran, the appellant, the Veteran’s sister, and the Veteran’s friend, which generally describe PTSD symptoms and impairment consistent with the criteria for a 70 percent rating under DC 9411. Some such statements—and in particular, the appellant’s October 2016 statement—contain some references to delusions and/or hallucinations or severe memory loss. Notably, in the October 2016 statement, the appellant asserted that the Veteran: did not remember his grandson; had persistent delusions or hallucinations, with the Veteran being paranoid that his trash would be bugged and not allowing it to become more than half full; was a persistent danger of harming himself or others; was not able to perform his own personal hygiene or daily activities of living, as the appellant shaved him, cleaned his teeth and groomed his hair; and was disoriented to time and place. However, such symptomatology is very inconsistent with the extensive medical record including numerous VA examinations, which documents, at most, mild memory and concentration problems, but no disorientation whatsoever, normal thought processes and communication, no hallucinations or delusions, and no indication of inability to maintain hygiene or perform such other minimal activities of daily living, or of any persistent harm to the Veteran’s self or others. To the extent that such assertions contained in the October 2016 statement are inconsistent with the disability picture established by the rest of the considerable evidence of record, the Board finds them not credible. Finally, the Board notes a November 2016 report from a private psychologist. The report indicates an assessment of occupational and social impairment consistent with a 70 percent rating (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood). The report also notes that the Veteran reported “auditory and visual hallucinations consistent of hearing conversations and his name being called and seeing figures when no one is present,” and “intermittent inability to perform daily activities of living including maintenance of minimal personal hygiene.” However, the examiner, while citing evidence reviewed, did not cite any evidence, or any objective mental evaluation performed by the examiner, in support of these symptoms; the examiner did not, in short, provide any insight or medical assessment regarding these symptoms besides simply reiterating the reports of the Veteran. See LeShore v. Brown, 8 Vet. App. 406 (1995) (a bare transcription of lay history is not transformed into competent medical evidence merely because the transcriber happens to be a medical professional). Moreover, such reports by the Veteran are not consistent with the rest of the record, which reflects the Veteran repeatedly denying auditory or visual hallucinations, and none being noted on objective examination, and no other reports consistent with that noted on the November 2016 evaluation. The Board thus finds them not credible. While the Veteran generally denied any delusions or hallucinations at all, on September 2015 VA examination, he reported hearing voices during sleep, but not while awake; such symptoms do not rise to the level of “persistent delusions or hallucinations,” as contemplated in the 100 percent criteria under DC 9411, and, moreover, are inconsistent with the report given in November 2016. Accordingly, a rating in excess of 70 percent for PTSD is denied. 2. A rating in excess of 60 percent for ischemic heart disease prior to February 9, 2016, and in excess of 30 percent thereafter, is denied. The Veteran’s ischemic heart disease is rated under DC 7005 for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted for arteriosclerotic heart disease (coronary artery disease) with a documented history of coronary artery disease where a workload of greater than 7 METs, but not greater than 10 METs, results in dyspnea, fatigue, angina, dizziness, or syncope; or, continuous medication is required. A 30 percent rating is warranted for arteriosclerotic heart disease (coronary artery disease) with a documented history of coronary artery disease where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted where there is more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted with chronic congestive heart failure; or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). On September 1, 2015, VA examination, prior electrocardiogram (EKG) was noted to have shown left ventricular hypertrophy, and echocardiogram to have shown left ventricular ejection fraction (LVEF) of 60 percent. Interview-based METs test on examination revealed that the lowest activity level at which the Veteran reported the symptoms of dyspnea, fatigue, and angina was 3 greater than 3 METs but not greater than 5 METs, a level consistent with activities such as light yard work (weeding), mowing the lawn (power mower), and brisk walking (4 miles per hour). On February 9, 2016, VA examination, a prior 2012 echocardiogram was noted to have shown LVEF of 65 percent. On examination, estimated METs level due solely to the cardiac condition(s), resulting in the symptoms of dyspnea and fatigue, was greater than 5 METs but not greater than 7 METs, which was consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing the lawn (push mower), and heavy yard work (digging); the METs level was lower when nonservice-connected conditions were also taken into account. On September 15, 2016, VA heart conditions examination, echocardiogram was noted to have shown LVEF of 60 percent. Interview-based METs test at that time revealed that the Veteran reported symptoms of dyspnea and fatigue at an activity level as low as greater than 5 METs but not greater than 7 METs. Such VA examination findings reflect a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope—consistent with a 60 percent rating under DC 7005—prior to February 9, 2016, and a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope—consistent with a 30 percent rating under DC 7005—beginning February 9, 2016. VA treatment records do not contain findings contradicting those on either VA examination, or any other evidence supporting either a rating greater than of 60 percent for ischemic heart disease prior to February 9, 2016, or greater than 30 percent thereafter. Moreover, neither the appellant nor her attorney has identified any specific evidence supporting a higher rating during either time period. Accordingly, a rating in excess of 60 percent for ischemic heart disease prior to February 9, 2016, and in excess of 30 percent thereafter, is denied. 3. A rating in excess of 10 percent for a shell fragment wound left suborbital area with retained foreign body scar is denied. The Veteran’s left suborbital area scar is rated under DC 7804 for scar(s) that are unstable or painful. Under DC 7804: five or more scars that are unstable or painful are rated 30 percent; three or four scars that are unstable or painful are rated 20 percent; and one or two scars that are unstable or painful are rated 10 percent. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. If one or more scars are both unstable and painful, 10 percent is added to the rating that is based on the total number of unstable or painful scars. DC 7800 provides ratings for burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. DC 7800 provides that a skin disorder with one characteristic of disfigurement of the head, face, or neck is rated 10 percent. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent. 38 C.F.R. § 4.118 Note (1) to DC 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: Scar 5 or more inches (13 or more cm.) in length; Scar at least one-quarter inch (0.6 cm.) wide at the widest part; Surface contour of scar is elevated or depressed on palpation; Scar is adherent to underlying tissue; Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); Underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); Skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2) to DC 7800 provides that tissue loss of the auricle is to be rated under DC 6207 (loss of auricle), and anatomical loss of the eye under DC 6061 (anatomical loss of both eyes) or DC 6063 (anatomical loss of one eye), as appropriate. Note (3) provides that unretouched color photographs are to be taken into consideration when rating under these criteria. 38 C.F.R. § 4.118. On September 2015, February 2016, and September 2016 VA examinations, the Veteran’s left suborbital area scar was 3 by 0.1 centimeters length and width (at the widest part), with no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scar was noted to be mildly irritating with itching, but not unstable with frequent loss of covering of skin over the scar. On September 2016 VA eye examination, the Veteran reported tearing of both eyes for a few months with left eye itching for few weeks, and he was found to have no visual impairment or other eye residual disability due to his service-connected shell fragment wound and scar. Such left suborbital area scar disability, resulting in mild irritation with itching, approximates the criteria for a 10 percent rating under DC 7804 for one painful scar. None of the other criteria for a compensable rating for a scar of the face, or for any other residual disability, has been shown, and no explanation for how such criteria might have been met is shown in the record. Accordingly, a rating in excess of 10 percent for a shell fragment wound left suborbital area with retained foreign body scar is denied. 4. An effective date earlier than August 19, 2013, for the award of service connection for ischemic heart disease is denied. The effective date of an award of service connection for a disability may not be earlier than the date of receipt of claim unless the claim is received within one year of separation from service. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. On August 19, 2013, the Veteran submitted a statement in support of an ongoing claim for a TDIU and other claims. In the statement, he asserted that he was “also claiming Ischemic Heart Disease,” and along with the statement submitted a form identifying, and authorizing VA to obtain, records of private treatment for his ischemic heart disease. Approximately 10 days later, private medical records regarding the Veteran’s ischemic heart disease were submitted to VA. The record does not contain any earlier claim for service connection for a heart disability, and neither the appellant nor her attorney has not identified any or even asserted that any earlier claim was filed. Rather, as reflected in an October 2020 brief, the appellant’s attorney appears to contend that the Veteran should be awarded an earlier effective date for service connection for ischemic heart disease based on the fact that the disability had been diagnosed and treated as early as 2012. However, as no claim for service connection had been filed until August 19, 2013, there is no legal basis for the award of service connection prior to that date. Accordingly, the appellant’s earlier effective date claim must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 5. The claim of entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only is dismissed. A person eligible for substitution includes “a living person who would be eligible to receive accrued benefits due to the claimant under section 5121(a) of this title.” 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010(a). “Periodic monetary benefits” are benefits that the claimant is entitled to receive and are paid monthly. See Wilkes v. Principi, 16 Vet. App. 237, 241-42 (2002). The appellant’s claimed benefit of financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, is not a periodic monthly benefit, but rather one-time lump sum payment. Accordingly, such benefits cannot be considered accrued benefits, as such are defined as “periodic monetary benefits... authorized under law administered by [VA], to which a payee was entitled at his or her death under existing ratings for decisions or those based on evidence in the file at the date of death, and due and unpaid...” 38 U.S.C. § 5121(a); 38 C.F.R. § 3.1000(a); see Pappalardo v. Brown, 6 Vet. App. 63, 65 (1993) (a one-time payment for assistance for specially adapted housing does not qualify as a ‘periodic monetary benefit’ for purposes of 38 U.S.C. § 5121, because such benefits may be paid only once, and therefore is not payable as an accrued benefit); Gillis v. West, 11 Vet. App. 441 (1998) (holding that automobile purchase assistance is not an accrued benefit as a matter of law because, although such benefits may be paid more than once, payment is not made periodically, meaning at regular intervals). As such, the appellant is, as a matter of law, ineligible to receive such benefits as a substitute claimant. Accordingly, her claim for financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, must be denied. See Sabonis, 6 Vet. App. at 430. 6. A TDIU beginning April 12, 2012, is granted. Total disability ratings for compensation based on individual unemployability 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 disabilities, provided 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. §§ 3.340, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16(b). In determining whether an individual is unemployable by reason of service-connected disabilities, consideration must be given to the type of employment for which the veteran would be qualified, including consideration of education and occupational experience. Neither age nor intercurrent disability may be used as a basis for assignment of a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Prior to August 19, 2013, the Veteran’s service-connected disabilities were: PTSD, rated 70 percent; shell fragment wound scar of the left suborbital area, rated 10 percent; and shell fragment wound of the left buttock, erectile dysfunction, and scars of the left hip, stomach, and back, each rated noncompensable (0 percent). His combined rating for compensation was 70 percent. The Veteran initially filed a claim for a TDIU on April 12, 2012. As reflected in an October 2020 brief from her attorney, the appellant argues that a TDIU is warranted beginning the April 12, 2012, date of the Veteran’s claim for such benefits. In support of the Veteran’s TDIU claim, statements dated in June and October 2012, August 2013, and October 2016 from the Veteran, the appellant, the Veteran’s sister, and the Veteran’s friend were submitted asserting that, due to the Veteran’s PTSD, he had problems with authority and had to retire three years early due to his anger and hostility issues and inability to follow rules, respect authority, and get along with others; they further contended and that he was emotionally unstable and could not function or work around other people due to irritability, and was not stable enough to maintain employment. Information received from the Veteran’s employer in July 2013 reflects that the Veteran retired from his position as a letter carrier in February 2007, after working in that position since October 1979. In this case, the evidence as to whether, from April 12, 2012, to August 18, 2013, the Veteran’s service-connected disabilities—and, in particular, his PTSD—rendered him unable to secure or follow a substantially gainful occupation is mixed. VA treatment records reflect that in September 2011 the Veteran reported symptoms associated with his PTSD that included thoughts of not wanting to live, low motivation, and poor concentration. He reported similar symptoms in January 2013, and expressed frustration about not being able to find a job due to his kidney condition. In August 2013, he reported leaving his job at the Post Office three years before retirement due to the fact that he began having problems at work getting along with others, as well as medical problems. VA examinations of the Veteran’s PTSD in August 2013, September 2015, and January 2016 reflect assessments of somewhat moderate occupational impairment. In August 2013, he was assessed with occupational impairment with “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation,” although he was noted to continue to exhibit symptoms of PTSD that included depression, anxiety, anger, nightmares and argumentativeness. On September 2015 examination, the Veteran reported continuing to be unemployed, not working since 2007, and being unable to work due to his medical problems and his emotional distress (i.e. irritability, anger, depression); it was noted that he continued to experience symptoms of posttraumatic stress including intrusive memories, distressing dreams, avoidance behaviors, guilt feelings, feeling detached from others, irritability, and significant sleep disturbances, which were ongoing and caused clinically significant distress. However, the examiner attributed the Veteran’s depression and associated symptoms to nonservice-related factors rather than service, and assessed a level of occupational impairment with reduced reliability and productivity. On January 2016 VA examination, while it was noted that the Veteran exhibited clinically significant PTSD symptoms including avoidance, detachment, irritability, anger, hypervigilance, and sleep disturbances, it was noted also noted that, in terms of functional impact, he exhibited moderate impairments: he was often lacking motivation to complete tasks and participate in various activities; struggled to maintain a normal daily routine; exhibited significant difficulty getting along with other people and preferred to keep to himself; was is not involved in any hobbies or leisure activities; was socially withdrawn and easily agitated by others; and was easily stressed by his environment. The VA examiner further opined that the Veteran’s PTSD alone did not prevent him from performing sedentary type of work, noting an absence of a psychotic condition or any significant cognitive deficits that might prevent him from performing sedentary type of work. The Veteran was also given a VA examination in October 2018. At that time, it was noted that the Veteran’s symptoms had included distressing memories, distressing dreams, avoidance of or efforts to avoid external reminders that arouse memories, thoughts, or feelings associated with events, diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior, hypervigilance, concentration difficulty, and sleep disturbance. They had also included social withdrawal, agitation, anxiety, paranoid ideation/suspiciousness, and depressive symptoms (depressed mood, loss of interest, feeling fatigue, feelings of worthlessness, and infrequent suicidal ideation). The examiner assessed that, in terms of functioning level, the Veteran seemed to be exhibiting mild limitations in the areas of remember or applying information, but noticeable limitations in relating to and working with supervisors, co-workers, and others, and in trying to adapt and manage oneself. The examiner assessed that, though he seemed able to understand and learn terms, instructions, and procedures, recall and carry out tasks, and complete tasks in a timely manner, his ability to cooperate with others, adapt to changes in a work-related environment, and properly manage symptoms in an effective manner may be difficult for him now, citing VA treatment notes dated June to August 2015 in support of this conclusion. Given the mixed evidence above as to whether the Veteran was unable to secure or follow a substantially gainful occupation due to his service-connected PTSD alone, and as early as April 12, 2012—including his limitations in relating to and working with supervisors and co-workers, trying to adapt to changes in a work-related environment, and properly managing symptoms in an effective manner— the Board finds it to be in relative equipoise on that question. Resolving reasonable doubt in the appellant’s favor, the Board finds that the Veteran’s service-connected disabilities, and specifically his PTSD, rendered him unemployable from the April 12, 2012, date of his claim for a TDIU. Accordingly, a TDIU beginning April 12, 2012, is granted. 7. SMC pursuant to 1114(s) beginning August 19, 2013, is granted. SMC provided by 38 U.S.C. § 1114(s) is payable where a veteran has a single service-connected disability rated as total and either (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, 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). For purposes of satisfying the requirements of 38 U.S.C. § 1114(s), a TDIU may be considered a total rating. See Bradley v. Peake, 22 Vet. App. 280, 291-93 (2008). However, multiple disabilities, even if able to be combined and considered as a single disability for purposes of 38 C.F.R. § 4.16(a), do not meet the criteria for “a service-connected disability rated as total” for SMC under 38 U.S.C. § 1114(s). Id. at 290-91. As discussed above, the Board finds—resolving reasonable doubt in the appellant’s favor—that a TDIU was warranted for the Veteran’s service-connected disability of PTSD beginning April 12, 2012; therefore, his PTSD had a total rating for purposes of 38 U.S.C. § 1114(s) as of that date. Effective August 19, 2013, the Veteran’s service-connected disabilities also included: shell fragment wound of the left buttock with left hip Paget’s disease with strain, rated 40 percent; ischemic heart disease rated 60 percent prior to February 9, 2016, and 30 percent thereafter; and shell fragment wound left suborbital area scar, rated 10 percent. His service-connected disabilities during this period, other than PTSD, were thus rated 60 percent or greater. See 38 C.F.R. § 4.25. Therefore, as of August 19, 2013, the Veteran had both a single service-connected disability (PTSD) rated as total and additional service-connected disabilities independently ratable at 60 percent or more, separate and distinct from PTSD and involving different anatomical segments or bodily systems. Accordingly, SMC pursuant to 38 U.S.C. § 1114(s) beginning August 19, 2013, is granted. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Andrew Mack, 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.