Citation Nr: 21023366 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 19-06 109A DATE: April 20, 2021 ORDER A disability rating in excess of 50 percent for service-connected bilateral hearing loss is denied. An initial rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted. REMANDED Entitlement to service connection for headaches to include as secondary to service-connected diplopia of the left eye is remanded. Entitlement to service connection for a disability manifested by twitching and pain near the left eye (claimed as nerve damage) to include as secondary to service-connected diplopia of the left eye is remanded. FINDINGS OF FACT 1. Audiometric testing revealed no worse than Level VI hearing acuity in the right ear and Level XI hearing in the left ear. 2. The evidence of record shows that the Veteran’s service-connected PTSD is manifested by deficiencies in most areas of social functioning and occupational functioning throughout the entire appeal period including irritability, bad temper, depressed mood, anxiety, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and inability to establish and maintain effective relationship; but symptoms and overall impairment caused by PTSD does not more nearly approximate total occupational and social impairment. 3. The evidence is at least evenly balanced as to whether the Veteran is unable to secure or follow a substantially gainful occupation due to service-connected PTSD and bilateral hearing loss from August 8, 2018. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for service-connected bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5103, 5103A; 38 C.F.R. §§ 3.159, 3.321, 4.85, 4.86 Diagnostic Code 6100. 2. The criteria for an initial rating in excess of 70 percent for service-connected PTSD are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for a TDIU due to service-connected disabilities are met. 38 U.S.C. §§ 1155, 7104; 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.16(a) and (b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1967 to September 1969. This case is before the Board of Veterans’ Appeals (Board) on appeal from an October 2018 Regional Office (RO) rating decision. In that rating decision, the RO granted service connection for PTSD, and assigned an initial 70 percent disability rating, effective from August 8, 2018, denied service connection for nerve damage and migraine headaches, denied a disability rating in excess of 50 percent for service-connected bilateral hearing loss and denied a TDIU. The Veteran’s notice of disagreement (NOD) was received in October 2018. The RO issued a statement of the case (SOC) in February 2019. The Veteran’s VA Form 9, substantive appeal to the Board, was received in March 2019. In August 2020, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of the testimony is associated with the claims file. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 1. Entitlement to a disability rating in excess of 50 percent for service-connected bilateral hearing loss. The Veteran contends that he is entitled to a higher disability rating for bilateral hearing loss, because he is unable to sustain gainful employment in part due to his hearing loss disability. Relevant laws and regulations stipulate that evaluations of defective hearing range from noncompensable to 100 percent based on the organic impairment of hearing acuity. Hearing impairment is measured by the results of controlled speech discrimination tests together with the average hearing threshold levels (which in turn, are measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second (Hertz)). See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992) (defective hearing is rated based on a mere mechanical application of the rating criteria). The provisions of 38 C.F.R. § 4.85 establish eleven auditory acuity levels from I to XI. If hearing loss is service-connected for only one ear, in order to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman numeral designation for hearing impairment of I. 38 C.F.R. § 4.85(f). Tables VI and VII as set forth in section 4.85(h) are used to calculate the rating to be assigned. In guidance for cases involving exceptional patterns of hearing impairment, the schedular criteria stipulates that, when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Each ear is evaluated separately. Additionally, when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. 38 C.F.R. § 4.86(b). The numeral will then be elevated to the next higher Roman numeral. Id. Each ear will be evaluated separately. Regarding the evidence of record, the Veteran underwent a VA examination in June 2018. This examination was conducted within one year prior to the August 8, 2018 increased rating claim and therefore, it is relevant to the issue of whether the Veteran is entitled to a higher disability rating for bilateral hearing loss. See 38 C.F.R. § 3.400(o)(2). The June 2018 VA audiology examination report reveals that the Veteran reported that he has difficulty hearing in all situations without his hearing aids. He stated that he still has difficulty hearing when background noise is present with his hearing aids. Speech recognition, using the Maryland CNC Word List, was 98 percent in the right ear and 0 percent in the left ear. On audiometric testing, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 60 65 80 85 73 LEFT 105+ 100 105+ 105+ 104 Applying the method for evaluating hearing loss to the results of the Veteran’s audiological evaluation reveals the exception requirements for hearing impairment under 38 C.F.R. § 4.86 applies in both ears. Specifically, both ears demonstrated an exceptional patten of hearing impairment as the results show a pure tone threshold 55 dB or more at each of the four specified frequencies under 38 C.F.R. § 4.86(a). Thus, the Veteran’s hearing impairment will be evaluated under either Table VI or Table VIa, whichever results in the higher numeral. The Veteran’s hearing acuity in right ear is ear is assigned to Level II and hearing acuity in the left ear is assigned to Level XI according to Table VI. The Veteran’s hearing acuity in the right ear is assigned to Level VI under Table VIa, resulting in a higher numeral for the right ear. The left ear is assigned to Level X using Table VIa, resulting in lower numeral for the left ear. Combining Level VI hearing for the right ear and Level XI hearing for the left ear according to Table VII reveals a 50 percent rating. 38 C.F.R. § 4.85, Diagnostic Code 6100. Accordingly, the June 2018 VA examination reveals that a 50 percent disability rating is warranted for the Veteran’s bilateral hearing loss disability. The Veteran underwent another VA examination in September 2018. The Veteran reported that he is currently using VA issued hearing devices. His hearing seems to have gotten worse and he has difficulty understanding speech when background noise is present. Speech recognition, using the Maryland CNC Word List, was 84 percent in the right ear and 0 percent in the left ear. On audiometric testing, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 55 65 75 90 71 LEFT 105+ 100 105+ 105+ 105 Applying the method for evaluating hearing loss to the results of the Veteran’s audiological evaluation reveals the exception requirements for hearing impairment under 38 C.F.R. § 4.86 applies in both ears. Specifically, both ears demonstrated an exceptional patten of hearing impairment as the results show a pure tone threshold 55 dB or more at each of the four specified frequencies under 38 C.F.R. § 4.86(a). Thus, the Veteran’s hearing impairment will be evaluated under either Table VI or Table VIa, whichever results in the higher numeral. The Veteran’s hearing acuity in right ear is ear is assigned to Level III and hearing acuity in the left ear is assigned to Level XI according to Table VI. The Veteran’s hearing acuity in the right ear is assigned to Level VI under Table VIa, resulting in a higher numeral for the right ear. The left ear is assigned to Level XI using Table VIa, resulting in the same numeral for the left ear. Combining Level VI hearing for the right ear and Level XI hearing for the left ear according to Table VII reveals a 50 percent rating. 38 C.F.R. § 4.85, Diagnostic Code 6100. Thus, the September 2018 VA examination reveals that a 50 percent disability rating is warranted for the Veteran’s bilateral hearing loss disability. The Board has considered the Veteran’s complaints regarding the impact of hearing loss on his daily life, but as noted above, the assignment of disability ratings for hearing impairment is primarily derived from a mechanical formula based on levels of pure tone threshold average and speech discrimination. Lendenmann, 3 Vet. App. 345. The functional effects of hearing loss on his daily life activities and occupational functioning were discussed by the Veteran at his VA examinations. See 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran is noted to have reported that he has trouble hearing and people sound like they are jumbled up, he cannot understand what people are saying, and he has problems hearing even with his hearing aids, this is reflective of the types of functional difficulty that would be expected to be caused by his recorded levels of hearing loss. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (manifestations such as difficulty hearing speech are the types of difficulties contemplated by the schedular criteria for hearing loss.). Accordingly, the examinations of record are sufficiently in compliance with the provisions of VA regulations, and they are afforded great probative value in determining the Veteran’s level of hearing impairment. Under these circumstances, the Board finds that the record presents no basis for assignment of a disability rating in excess of 50 percent for the Veteran’s service-connected bilateral hearing loss at any time during the appeal period. Accordingly, the claim for increased evaluation for his bilateral hearing loss must be denied based on the evidence of record at this time. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.85, 4.86. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to an initial rating in excess of 70 percent for service-connected PTSD. The Veteran contends that his PTSD warrants a higher disability rating, because his PTSD symptoms, in part, result in the Veteran being unable to sustain gainful employment. When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. The Veteran’s service-connected PTSD is currently rated as 70 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411 for PTSD. PTSD is rated pursuant to the General Rating Formula for Mental Disorders. Id. Under the General Rating Formula for Mental Disorders, a 70 percent rating is prescribed for 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 work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. 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; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the Veteran’s social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining whether the Veteran meets the criteria for a 70 percent rating, the Board must consider whether the Veteran has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, or mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). Furthermore, the Court has held that entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The medical evidence of record consists of VA treatment records and an August 2018 VA examination. Furthermore, lay statements from the Veteran and a transcript of the August 2020 Board hearing provide additional information about the Veteran’s PTSD symptoms. This evidence, the most pertinent of which is summarized below, shows that the Veteran’s condition does not more closely approximate total occupation and social impairment. Accordingly, the preponderance of the medical and lay evidence shows that a rating in excess of 70 percent is not warranted at any point during the appeal as the Veteran’s symptoms do not more nearly approximate the requirements for a 100 percent disability rating at any time during the appeal period. In this regard, the medical and lay evidence shows that the Veteran did not have 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; or memory loss for names of close relatives, own occupation, or own name. The Veteran also did not have other symptoms of similar severity and frequency. See VA examination dated in August 2018 and VA treatment records dated in April 2020 and June 2020. Specifically, an August 2018 VA examination reveals that the Veteran’s thought process was linear and organized with no flight of ideas, obsessions, or preoccupations A June 2020 VA treatment record shows that the Veteran’s thought process was mildly perseverative, associations were logical, VA treatment records dated in April 2020 and May 2020 reveal that the Veteran’s thought process was a bit slow, but reasoning was intact. Associations were circumstantial. The Veteran’s speech was normal for rate and volume. See August 2018 VA examination and VA treatment records dated in June 2002, May 2020, and April 2020. The Veteran was alert and consistently oriented to person, place, and time throughout the appeal period. The Veteran experiences mild memory loss; however, VA treatment records indicate recent and remote memory were intact. See VA treatment records dated in June 2020, May 2020, and April 2020. The August 2018 VA examiner observed that the Veteran’s behavior was calm and pleasant with good eye contact and no tremors or abnormal movement. The Veteran has consistently denied hallucinations, delusions, or obsessions. Although the August 2018 VA examiner noted that the Veteran looked mildly disheveled, wearing shorts and a stained t-shirt, the overall evidence reflects that the Veteran is able to maintain minimal personal hygiene. He is able to complete regular household chores and complete self-care (i.e., dressing and showering) independently and regularly. The evidence shows that the Veteran experienced thoughts of hopelessness and thoughts of it being better without him around. However, the Veteran has consistently denied any overt suicide thoughts. Thus, there is some evidence of passive suicidal ideation without specific intent, but these thoughts are not severe enough to be analogous to persistent danger of hurting oneself. The Veteran has consistently denied homicidal ideation. The lay and medical evidence reflects that the Veteran’s symptoms of PTSD impact his ability to work and his social relationships. In this regard, the Veteran is currently unemployed, and he last worked at the age of 59, when he went on unemployment. He worked in property managements and he was fired from this position. The Veteran explained that he tried to find work after he lost his job, but he could not find any work due to his age. Currently, the Veteran’s symptoms of PTSD include depressed mood, anxiety, mild memory loss, disturbances in motivation and mood, difficulty in establishing effective work relationships, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. While these symptoms would have a significant impact on the Veteran’s ability to work, it does result in total occupational impairment. With respect to social impairment, the evidence shows that the Veteran was married twice, and he is now divorced. His most recent marriage was from 1981 to 1983. The Veteran reported at the August 2018 VA examination that he was not currently in a romantic relationship. He has two adult children and three grandchildren. He described his relationship with his daughter as tenuous and his relationship with his son as very good. He reported limited other close relationships. A May 2020 VA treatment record documents that the Veteran lives with his son in an in-law apartment. He does his son’s yardwork. He also enjoys and sees his grandchildren (son’ children) daily. Therefore, as the evidence shows that the Veteran has good relationship with his son and grandchildren, the evidence does not reflect that his PTSD symptoms result in total social impairment. Accordingly, the evidence of record reflects that neither the symptoms nor overall impairment caused by the Veteran’s PTSD more nearly approximate total occupational and social impairment. Therefore, a 100 percent disability rating for PTSD is not warranted at any time during the appeal period. 3. Entitlement to a TDIU due to service-connected disabilities. The Veteran contends that his service-connected PTSD and bilateral hearing loss prevent his from securing or following any substantially gainful occupation. See October 2019 NOD. Total disability will be considered to exist when there is present any impairment of mind or body, which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. In order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 C.F.R. § 3.340(a), a veteran is not required to submit proof that he is 100 percent unemployable. See Roberson v. Principi, 251 F.3d 1378, 1385 (2001). Instead, the regulations contemplate more flexibility in the employability determination. Id. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he or she has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). It is provided further that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. The Veteran’s service-connected disabilities are as follows: PTSD, evaluated as 70 percent disabling from August 8, 2018; bilateral hearing loss, evaluated as 50 percent disabling from April 18, 2018; left wrist condition, evaluated as 10 percent disabling from April 18, 2018; and diplopia of the left eye, evaluated as noncompensable from September 9, 1969. The combined evaluation for compensation was 60 percent from April 18, 2018 and 90 percent from August 8, 2018. Thus, the Veteran meets the schedular criteria for an award of TDIU pursuant to the provisions of 38 C.F.R. § 4.16(a) from the date of the TDIU claim. The crucial inquiry in determining whether the Veteran is entitled to TDIU is not whether the Veteran is able to pursue his profession of choice, or indeed any particular job. Instead, the Board must inquire as to whether the Veteran can secure and follow a substantially gainful occupation in a more general sense. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a veteran is unemployed is not enough. It must be determined that his service-connected disorders without regard to his advancing age make him incapable of performing the acts required by employment. Id. In this case, the collective evidence suggests that the Veteran’s service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation throughout the appeal period. Specifically, the evidence shows that the Veteran was unemployed throughout the relevant appeal period.  The Veteran reported that the last date he worked full time was in October 2005 and he became too disabled to work in October 2005. The Veteran reported that he completed four years of college. Turning to the medical evidence of record, an August 2018 PTSD VA examination shows the Veteran’s PTSD symptoms include depressed mood, anxiety, mild memory loss, such as forgetting names, directions, or recent event, disturbances in 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 inability to establish and maintain effective relationships. The Veteran was mildly disheveled at the examination and he was wearing shorts and a stained t-shirt. The examiner noted that the Veteran reported that ongoing symptoms of re-experiencing of the traumatic event, avoidance, negative alterations in mood and cognition, and arousal symptoms. The examiner concluded that the Veteran’s symptomatology result in moderate, functional impairment in areas such as ability to maintain relationships, concentrate, cope with stress, and maintain stable mood/motivation. However, the examiner determined that the Veteran’s PTSD symptoms are not likely to directly impair the his ability to function in an employment setting given that he worked in various positions in property management until he was let go from his job and he was unable to find another position. A September 2018 VA examination for hearing loss shows that the VA examiner determined that the Veteran’s hearing loss impacts ordinary conditions of daily life including ability to work. The Veteran reported that he is currently using VA issued hearing devices. His hearing seems to have gotten worse and he has difficulty understanding speech when background noise is present. The medical evidence reflects that the Veteran has moderate to sensorineural hearing loss in right ear and that significant sensorineural hearing loss in left ear that basically results almost no hearing in the left ear as the speech discrimination score in the left ear was 0 percent. April 2020 and May 2020 VA behavioral telehealth records document that the veteran’s thought process was a little slow at times, but reasoning was intact. Associations were circumstantial. The Veteran appeared mildly irritated with the psychiatrist’s questions at times. A June 2020 VA examination shows that the Veteran’s thought process mildly perseverative and his affect was mildly anxious. He demonstrated mild depression and passive suicidal ideation. The Veteran testified at the Board hearing that when he takes his hearing aids out, he cannot hear anything, and he is essentially deaf. He noted that his daughter-in-law is very soft spoken, and he does not understand anything she says and the same thing with his grandchildren. The hearing transcript reflects that the Veteran had difficulty with hearing during the proceedings and he had to ask for questions and statements to be repeated several times for him to hear. The testified that having a regular conversation with people is very difficult in any environment, but particularly a work or classroom environment. With respect to his PTSD symptoms, the Veteran testified that he gets very anxious and overwhelmed if he watches a movie with a lot physical violence. He also indicated that he experiences panic attacks in these situations. The Veteran testified that his symptoms result in him being irritable and short-tempered. He stated that he has lost half of his friends because of his short temper. It also interferes with his relationships with his family and he attributed his irritability and tempter to the cause of his divorce. The Veteran also testified that he believes he would not last a week in an employment setting due to his irritability. He noted that he was fired from his last job in property management because he was combative. The ultimate question of whether a veteran is capable of substantially gainful employment is not a medical question, but rather a determination that must be made by an adjudicator. See 38 C.F.R. § 4.16 (a); Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2014) and Floore v. Shinseki, 26 Vet. App. 376, 381 (2013)). However, as a medical examiner is responsible for providing a full description of the functional effects of disability upon a person’s ordinary activity (see 38 C.F.R. § 4.10), and has done so here. The findings, comments and opinions of the VA examiners have appropriately been considered as pertinent evidence, along with the Veteran’s competent assertions, in determining whether he is able to perform the acts required for substantially gainful employment. Based on the foregoing, the Board finds that the overall evidence of record indicates that Veteran would be unable to maintain employment due to his service-connected PTSD and bilateral hearing loss from August 8, 2018. Specifically, the medical and lay evidence shows that the Veteran’s service-connected bilateral hearing loss would make it dangerous for him to work in most physical or manual labor positions. In addition, he would have difficulty working in a sedentary or office setting due to his severe hearing loss disability. Furthermore, the medical and lay evidence reflects that his PTSD symptoms including irritability, bad temper, depressed mood, anxiety, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective relationship would have a significant impact on the Veteran’s ability to maintain employment that requires interaction with others. The combined effect of the Veteran’s service-connected PTSD and bilateral hearing loss would allow only marginal employment at best, given the restrictions the disabilities would put on the Veteran finding adequate employment. See Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994) (TDIU may not be denied without producing evidence, as distinguished from mere conjecture, that the Veteran’s disability does not prevent him or her from performing work that would produce sufficient income to be other than marginal). In light of the foregoing, the evidence is at least evenly balanced as to whether the Veteran is precluded by the combined effects of his service-connected PTSD and bilateral hearing loss from August 8, 2018 from obtaining and maintaining substantially gainful employment in occupations related to his education, training, and work experience. Resolving any reasonable doubt in favor of the Veteran, a TDIU is warranted from August 8, 2018 REASONS FOR REMAND 1. Entitlement to service connection for headaches to include as secondary to service-connected diplopia of the left eye. A remand is necessary prior to adjudicating the claims on appeal. In this regard, the Veteran contends that he has experienced recurrent headaches ever since in the in-service left orbital fracture. During a May 1970 VA examination, the Veteran reported that he cannot read for any length of time without getting headaches. A VA examiner in August 2018 provided the medical opinion that the Veteran’s claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained there is no mention of headaches in his primary care documentation and it would be highly unusual for a new headache syndrome to begin more than 50 years after an assault, such as the one described above. The Veteran is competent to report that he experiences headaches, as well as, the onset of such headaches as this is an observable symptom capable of lay observation. Furthermore, the medical record documents that the Veteran reported experiencing headaches within one year of discharge from active duty service. The August 2018 VA medical opinion is inadequate as the examiner did not address the Veteran’s lay statements as to onset of his headaches or the medical record that documents that the Veteran reported experiencing headaches within one year after discharge from service. Furthermore, the examiner did not provide a medical regarding whether the Veteran’s current headaches are caused or aggravated by service-connected diplopia of the left eye. Thus, the Veteran must be provided with another VA examination and medical opinion. 2. Entitlement to service connection for a disability manifested by twitching and pain near the left eye (claimed as nerve damage) to include as secondary to service-connected diplopia of the left eye is remanded. The Veteran contends that he experiences pain and twitching in or near his left eye that is related to the in-service blowout fracture of the floor of the left orbit and/or secondary to service-connected diplopia of the left. The Veteran was provided with a cranial nerve examination in August 2018. The examiner determined that the Veteran did not have a diagnosed cranial nerve disability. The examiner noted that the Veteran reported that his left lower eyelid twitches sometimes. The examiner determined that the Veteran is most likely describing fasciculations, which are normal intermittent twitching, most typically located in the small muscles around the eye. They can be precipitated by excess caffeine consumption or stress and are benign and self-limited. This is not a cranial neuropathy. Therefore, it is less likely than not that the Veteran has nerve damage around his left eye that was incurred in or caused by the orbital fracture during service. However, the examiner did not address the Veteran’s symptom of pain in or near the left eye. The examiner also did not address whether it was secondary to his service-connected diplopia of the left eye. Accordingly, a remand is necessary to obtain a new VA examination and medical opinion. The matters are REMANDED for the following action: 1. Arrange for the Veteran to undergo a VA examination to determine the current nature and likely etiology of the Veteran’s headaches. The claims file and a copy of this remand must be made available to the examiner for review and the examination report should reflect that the claims file was reviewed in connection with the examination. All indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer an opinion on the following: (a). Whether any headache disability found on examination or documented in the claims file (at any time during the relevant appeal period) at least as likely as not (i.e., a fifty percent or greater probability) had its onset during active military service or is otherwise related to active military service to include the documented in-service blowout fracture of the floor of the left orbit. The examiner must provide an explanation for all conclusions reached. As part of his or her explanation, the examiner must discuss the May 1970 VA examination that documents that the Veteran reported experiencing headaches and his lay statements of recurrent headaches since the incident in service. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. The examiner cannot dismiss the Veteran’s allegations headaches in service solely because it is not documented in the Veteran’s service treatment records, although the lack of contemporaneous documentation can be a factor considered if the examiner explains why such would likely be documented in the Veteran’s service treatment records. The examiner also may not dismiss the Veteran’s complaints of post-service symptoms solely because they are not documented in medical treatment records. (b). If the examiner determines that the Veteran’s headache is less likely than had its onset in or is otherwise related to service, then the medical specialist is asked to provide an opinion as to whether any headache disability found on examination or documented in the claims file (at any time during the relevant appeal period) is at least as likely as not (i.e., a fifty percent or greater probability) (i) caused by or (ii) aggravated by service-connected diplopia of the left eye. If aggravation is found, the medical specialist must attempt to establish the baseline level of severity of the headaches prior to aggravation by the service-connected disability. An explanation must be given for any opinion expressed. 2. Arrange for the Veteran to undergo a VA eye examination to determine the current nature and likely etiology of the Veteran’s disability manifested by twitching and pain near the left eye (claimed as nerve damage). The claims file and a copy of this remand must be made available to the examiner for review and the examination report should reflect that the claims file was reviewed in connection with the examination. All indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer an opinion on the following: (a). Identify the disability(ies) manifested by the symptoms of pain and twitching near/in the left eye diagnosed during the examination and/or documented in the medical records in the claims file at any time during the relevant appeal period. (b). If no disability is diagnosed, then whether the symptoms of pain and twitching near the left eye are symptoms of the blowout fracture of the floor of the left orbit that occurred during service. (c). If the examiner identifies a disability manifested by the symptoms of pain and twitching near the left eye, then whether the disability found on examination or documented in the claims file (at any time during the relevant appeal period) at least as likely as not (i.e., a fifty percent or greater probability) had its onset during active military service or is otherwise related to active military service to include the documented in-service blowout fracture of the floor of the left orbit. The examiner must provide an explanation for all conclusions reached. As part of his or her explanation, the examiner must discuss the Veteran’s lay statements of pain and twitching below the eye since the incident in service. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. The examiner cannot dismiss the Veteran’s allegations of pain and twitching near the left eye in service solely because it is not documented in the Veteran’s service treatment records, although the lack of contemporaneous documentation can be a factor considered if the examiner explains why such would likely be documented in the Veteran’s service treatment records. The examiner also may not dismiss the Veteran’s complaints of post-service symptoms solely because they are not documented in medical treatment records. (d). If the examiner determines that the Veteran’s disability is less likely than had its onset in or is otherwise related to service, then the examiner is asked to provide an opinion as to whether any disability found on examination or documented in the claims file (at any time during the relevant appeal period) is at least as likely as not (i.e., a fifty percent or greater probability) (i) caused by or (ii) aggravated by the service-connected diplopia of the left eye. If aggravation is found, the medical specialist must attempt to establish the baseline level of severity of the disability manifested by pain and twitching prior to aggravation by the service-connected disability. (Continued on the next page)   An explanation must be given for any opinion expressed. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Berry, 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.