Citation Nr: 21007428 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 11-26 648A DATE: February 9, 2021 REMANDED Entitlement to service connection for bilateral leg disability is remanded. Entitlement to an initial disability rating in excess of 10 percent for instability of the right knee is remanded. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a disability rating in excess of 10 percent for bilateral pes planus prior to April 10, 2013, and in excess of 30 percent thereafter is remanded. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the right knee is remanded. Entitlement to a total disability rating based upon individualized unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2001 to February 2010. These matters come before the Board of Veterans’ Appeals (Board) on appeal from May 2010, July 2010, and January 2011 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In the October 2011 VA form 9, Substantive Appeal, the Veteran requested a Travel Board hearing. However, in November 2011, the Veteran informed VA personnel during a telephone call that he wished to withdraw his optional Board hearing request. See November 28, 2011, VA form 21-0820, Report of General Information. Thus, the Veteran’s hearing request is deemed as withdrawn. 38C.F.R. §20.603(e). The undersigned Veterans Law Judge has been assigned to consider this appeal pursuant to 38C.F.R. §20.106 (a). The Board remanded these issues in April 2018 and September 2019. There has been substantial compliance with the September 2019 Remand directives, however, additional development is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for bilateral leg disability; an initial disability rating in excess of 10 percent for instability of the right knee; a disability rating in excess of 10 percent for bilateral pes planus prior to April 10, 2013, and in excess of 30 percent thereafter; an initial disability rating in excess of 10 percent for degenerative joint disease of the right knee are remanded. At the outset, the Board notes that the Veteran reported receiving Social Security Disability benefits, but medical records have not been associated with the claims file nor was there any indication whether a search for those records was conducted. A remand is required to attempt to obtain Social Security Administration (SSA) records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, records from Federal agencies such as the SSA. 38 C.F.R. § 3.159 (c)(2). This includes relevant SSA records. Golz v. Shinseki, 590 F.3d 1317, 1321-23 (Fed. Cir. 2010). A June 2011 SSA Determination memo recommended that the onset date of the Veteran’s “inability to work” should be set as January 1, 2011. A February 2012 SSA Disability application indicated that the Veteran’s PTSD, knee and elbow disabilities, obstructive sleep apnea, and hypertension limited his ability to work. In a February 2013 Statement in Support of Claim, the Veteran confirmed he received SSA benefits due to PTSD. However, the Veteran’s SSA medical records are not currently in the claims file. Because it appears that there may be outstanding medical records and that the Veteran may be receiving SSA disability benefits due to the disabilities currently on appeal, the Board finds that a remand for all medical records held by SSA is necessary as it may impact the Veteran’s claim. See Quartuccio v. Principi, 16 Vet. App. 183, 187-88 (2002) (stating that “the possibility that the SSA records could contain relevant evidence... cannot be foreclosed absent a review of those records.”). Moreover, the record indicates that the South Carolina Vocational Rehabilitation Department processed the Veteran’s application for disability benefits on behalf of SSA, but such records have not been sought and associated with the claims file. Those records should be obtained. 2. Entitlement to an initial disability rating in excess of 30 percent for PTSD is remanded. The Veteran was last provided with a VA examination in 2010, approximately 11 years ago. The Veteran was scheduled to undergo a VA examination in January 2014, however, he was in Germany at the time and the examination was cancelled. An April 2014 Report of General Information indicated that the Veteran lives in Germany and in July 2014 the Veteran notified the RO that he would be returning to America in October 2014. He requested to undergo a VA examination prior to returning to Germany on November 3, 2014. There is no evidence that the RO attempted to reschedule a VA examination in October 2014 nor is there any evidence the RO scheduled a VA examination closer to the Veteran’s residence in Germany. An October 2019 medical report from Dr. U.L. MD noted that the Veteran’s PTSD increased and recommended he be assigned a 100% disability rating. The Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. 38 C.F.R. § 3.327; Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994) (finding that a 23-month-old VA examination was too remote in time where evidence of worsening symptoms was submitted in the interim). Therefore, remand for a VA examination is necessary prior to adjudication. 3. Entitlement TDIU is remanded. The record reflects the Veteran believes that his service-connected disabilities preclude him from substantially gainful employment. The Board has taken jurisdiction of the TDIU issue per Rice v. Shinseki, 22 Vet. App. 447 (2009). The TDIU issue is inextricably intertwined with the claim remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991). Opinions should be sought as to the effect the Veteran’s disabilities on his ability to maintain gainful employment. The matters are REMANDED for the following action: 1. Obtain the Veteran’s SSA records. 2. Obtain an updated VA 21-8940 from the Veteran. Inform the Veteran that if he does not return the completed form, his claim for entitlement to TDIU may be considered abandoned. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected psychiatric disorder alone. (Continued on the next page)   4. Schedule the Veteran for an examination by an appropriate clinician to determine the functional impairment resulting from his service-connected disabilities which would hamper or preclude him from gainful employment. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mohammad Mahmoudi, 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.