Citation Nr: 21006429
Decision Date: 02/04/21	Archive Date: 02/04/21

DOCKET NO. 07-37 351
DATE: February 4, 2021

REMANDED

Entitlement to a total disability evaluation based on individual unemployability (TDIU).

REASONS FOR REMAND

The Veteran served on active duty from September 1990 to February 1991, January 1992 to January 1993, and from May 2002 to April 2005.

This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which involved other issues that are no longer a part of this current appeal.  In March 2011, the Board found that the issue of entitlement to a TDIU had been raised.  In June 2015, the Board remanded the issue of entitlement to a TDIU.  The Board last remanded the claim in June 2017 for further development.

The Veteran provided testimony at a hearing before the undersigned in November 2010 at the Montgomery, RO.  A transcript of this hearing is of record. 

Discussion

The Veteran asserts that she is unable to secure and follow substantially gainful employment due to the following service-connected disabilities: migraine headaches; cervical spine degenerative disc disease and spondylosis C5-6; status post right shoulder Bankhart procedure; thoracolumbar spine degenerative disc disease; dextroscoliosis; levoscoliosis; diffuse spondylosis; recurrent bilateral tinnitus; Posttraumatic Stress Disorder (PTSD); and, temporomandibular joint disorder.  The Board finds that there was not substantial compliance with the Board’s June 2017 remand directives, wherein it was directed to obtain a “combined effects” VA medical opinion.  See Stegall v. West, 11 Vet. App. 268, 271 (1998).

In light of the remand, updated VA treatment record should be obtained.

The matter is REMANDED for the following action:

1. Obtain VA treatment records dated since September 2020.  

2. Schedule the Veteran for an examination by an appropriate clinician.  The claims file should be made available to the examiner and review of the file should be noted in the requested report.  All findings must be reported in detail.

Following review of the claims file and examination of the Veteran, if necessary, and after considering the Veteran's reported work history, the examiner should offer an opinion discussing the impact of the Veteran's service-connected disabilities (migraine headaches; cervical spine degenerative disc disease and spondylosis C5-6; status post right shoulder Bankhart procedure; thoracolumbar spine degenerative disc disease, dextroscoliosis, levoscoliosis, and diffuse spondylosis; recurrent bilateral tinnitus; PTSD; and, temporomandibular joint disorder, ) collectively on his ability to secure or follow a substantially gainful occupation.  The clinician's opinion should include an evaluation of the limitations and restrictions imposed by his service-connected impairments on such routine work activities as interacting with coworkers, sitting, standing, walking, lifting, carrying, pushing, and pulling.

All findings and conclusions should be supported with a complete rationale that considers the relevant medical and lay evidence of record.  If unable to opine without speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge.

 

 

K.A. KENNERLY

Acting Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	S. Becton, 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.