Citation Nr: 21016198 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 16-07 554 DATE: March 22, 2021 REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to total disability due to individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2001 to August 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. The Veteran’s posttraumatic stress disorder (PTSD) was initially service connected in a September 2014 rating decision with a rating of 50 percent, effective April 22, 2014. The Veteran timely filed a notice of disagreement in August 2015. Following a December 2015 statement of the case, the Veteran perfected his appeal with a timely filed Form 9, in February 2016. Evidence of record shows that the Veteran has received both private and VA treatment for his service-connected PTSD. However, the record contains no treatment records since 2014. Similarly, the Veteran’s only VA examination for his PTSD was in September 2014. In his notice of disagreement and February 2016 correspondence, the Veteran alleged symptoms that were more severe than those noted in his 2014 treatment records and VA examination. Specifically, in his statement received in February 2016, the Veteran alleged that he currently suffers from occupational and social impairment with deficiencies in most areas including an inability to keep a job, neglect of person appearance and hygiene and inability to adapt to stressful circumstances. The Veteran also reported panic attacks more than once a week, and panic attacks occurring daily when he is working. The Veteran also alleged an inability to establish and maintain effective relationships. This suggests a worsening of the Veteran’s symptoms. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). As such, remand is warranted for a new VA examination to assess the current severity of the Veteran’s service-connected PTSD. 2. Entitlement to total disability due to individual unemployability. When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to a TDIU will be considered to have been raised by the record as "part and parcel" of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disabilities to bring the combination to 70 percent or more. 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Here, the Veteran has alleged that he is unable to maintain employment because of his service-connected PTSD. As such, the Board finds that a claim for TDIU is raised by the record. The record does not contain sufficient information about the Veteran’s level of education, special training and previous work experience to render a decision on TDIU. Remand is warranted to afford the Veteran the opportunity to provide additional information regarding his education, training and employment history to support a claim for entitlement to TDIU. The record is also unclear as to whether the Veteran receives Social Security Disability. Such should be ascertained on remand. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records from 2014 to present. 2. Determine if the Veteran receives Social Security disability. If so, obtain all records regarding that determination to include adjudication and medical records. 3. Ask the Veteran to complete a VA Form 21-4142 for all private treatment providers for his service-connected PTSD for the period from 2014 to present. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. All attempts to obtain records should be documented in the file. 4. Ask the Veteran to complete VA form 21-8940 in order to provide information regarding his education, special training and employment history. 5. After all outstanding treatment records have been obtained, 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. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Wimbish, 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.