Citation Nr: 21012653 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 17-52 713 DATE: March 4, 2021 REMANDED Entitlement to a disability evaluation in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1964 to November 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in September 2020; a transcript is of record. 1. Entitlement to a disability evaluation in excess of 30 percent for service-connected PTSD is remanded. The Veteran testified during his September 2020 hearing that his condition has worsened since his previous examination in August 2016. As it has been approximately four years since the Veteran’s latest examination, and the Veteran asserts that his condition has increased in severity since said examination, the Board finds that a new examination is warranted to ascertain the current nature and severity of his service-connected PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Further, the Board notes that the most recent medical records associated with the claims file as relate to the Veteran’s psychiatric condition are dated March 2015. Because the Board is requesting a new examination, the Board also requests that the RO obtain the Veteran’s updated medical records prior to said examination. 2. Entitlement to a TDIU is remanded. The Board finds that the issue of entitlement to a TDIU, including as due to the Veteran’s service-connected PTSD, is reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009); see also 38 C.F.R. §§ 3.340, 4.16. The issue of TDIU is part and parcel of the increased rating claim and consequently is before the Board via the appeal of this issue. Rice, 22 Vet. App. at 453. The Veteran’s August 2016 examination notes that the Veteran’s employment changed from full time to part time and that his psychiatric condition adversely affects his ability to perform occupational tasks fully. See August 2016 VA C&P Examination. Accordingly, the Board finds these matters are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, as the Veteran’s claim for an increased disability evaluation for his service-connected PTSD is remanded, his claim for entitlement for a TDIU must be remanded as well. The matters are REMANDED for the following action: 1. The RO should request the Veteran to identify any and all VA and/or private medical records related to his service-connected PTSD from March 2015 to the present. Appropriate efforts must be made to obtain these records if he has adequately identified them and authorized their release (with respect to any private medical records). He should also be invited to submit these records himself. All actions to obtain the requested records must be fully documented in the claims file. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. 2. After completing the foregoing development, schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by a psychiatrist to determine the severity of his service-connected PTSD. In conjunction with the examination, the claims folder, including a copy of this remand, must be made available to the examiner for review and this review should be noted. All necessary diagnostic testing and evaluations should be performed, and all findings set forth in detail. If possible, the appropriate Disability Benefits Questionnaires (DBQs) should be completed. 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 PTSD alone. The examiner is asked to comment on and describe the functional impairment caused solely by the service-connected PTSD as it pertains to the Veteran’s ability to function in an occupational environment. The opinion need not state whether the Veteran’s PTSD prevents him from obtaining or maintaining substantially gainful employment. Rather, the examiner should discuss how and to what extent the Veteran’s service-connected PTSD affects his ability to perform occupational tasks. The examiner should, for instance, describe the limitations and restrictions imposed by his service-connected condition with respect to factors such as his ability to maintain energy and focus for up to eight hours per day, his ability to interact with co-workers and supervisors, and in terms of whether such disability might require absences from work and/or breaks from work. The examiner must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Seserman 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.