Citation Nr: 21040623 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 15-19 056 DATE: July 6, 2021 ORDER Entitlement to an evaluation in excess of 70 percent for schizophrenia is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to April 14, 2014, is denied. Entitlement to service connection for left knee degenerative joint disease, to include as secondary to medication taken for schizophrenia, is granted. Entitlement to service connection for right knee degenerative joint disease, to include as secondary to medication taken for schizophrenia, is granted. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for urinary incontinence as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for a left upper extremity tremor as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for a right upper extremity tremor as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left masked facies as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right masked facies as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left tardive dyskinesia as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right tardive dyskinesia as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left bradykinesia as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right bradykinesia as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left sided stooped posture as a complication of Parkinson's disease is denied. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right sided stooped posture as a complication of Parkinson's disease is denied. REMANDED Entitlement to an initial evaluation in excess of 20 percent for left sided bradykinesia as a complication of Parkinson's disease is remanded. Entitlement to an initial evaluation in excess of 20 percent for right sided bradykinesia as a complication of Parkinson's disease is remanded. Entitlement to an initial evaluation in excess of 10 percent for left sided stooped posture as a complication of Parkinson's disease is remanded. Entitlement to an initial disability evaluation in excess of 10 percent for right sided stooped posture as a complication of Parkinson's disease is remanded. Entitlement to an initial compensable evaluation for urinary incontinence as a complication of Parkinson's disease is remanded. Entitlement to an initial evaluation in excess of 30 percent for right sided upper extremity tremor as a complication of Parkinson's disease is remanded. Entitlement to an initial evaluation in excess of 20 percent for left sided upper extremity tremor as a complication of Parkinson's disease is remanded. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 20 percent from that date, for left sided masked facies as a complication of Parkinson's disease is remanded. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 20 percent from that date, for right sided masked facies as a complication of Parkinson's disease is remanded. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 10 percent from that date, for left sided tardive dyskinesia as a complication of Parkinson's disease is remanded. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 10 percent from that date, for right sided tardive dyskinesia as a complication of Parkinson's disease is remanded. FINDINGS OF FACT 1. The Veteran's schizophrenia is characterized by occupational and social impairment with deficiencies in most areas. 2. Prior to April 14, 2014, the functional impairment from the Veteran's service-connected disabilities did not effectively preclude all forms of substantially gainful employment for which the Veteran's education and occupational experience would otherwise make him qualified. 3. Giving every reasonable to the Veteran, his left knee degenerative joint disease is aggravated beyond its natural course by medication taken for schizophrenia. 4. Giving every reasonable to the Veteran, his right knee degenerative joint disease is aggravated beyond its natural course by medication taken for schizophrenia. 5. Service connection was not in effect for Parkinson's disease prior to April 14, 2014. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 70 percent for schizophrenia have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9211. 2. The criteria for a TDIU prior to April 14, 2014, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19. 3. The criteria for service connection for a left knee degenerative joint disease, to include as secondary to medication taken for schizophrenia, have been met. 38 U.S.C. §§ 1131, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for a right knee degenerative joint disease, to include as secondary to medication taken for schizophrenia, have been met. 38 U.S.C. §§ 1131, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for urinary incontinence as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 6. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for a left upper extremity tremor as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 7. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for a right upper extremity tremor as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 8. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for left masked facies as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 9. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for right masked facies as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 10. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for left tardive dyskinesia as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 11. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for right tardive dyskinesia as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 12. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for left bradykinesia as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 13. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for right bradykinesia as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 14. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for left sided stooped posture as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. 15. The criteria for an earlier effective date than April 14, 2014, for the grant of service connection for right sided stooped posture as a complication of Parkinson's disease have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1976 to July 1978. This claim was previously before the Board in September 2018, at which time the Board remanded it for additional development. The requested development has been completed, and the claim is properly before the Board for appellate consideration. The Veteran did not submit a VA Form 9 (Appeal to the Board of Veterans' Appeals) in response to the August 2019 statement of the case for the issues of entitlement to specially adapted housing and a special home adaption grant and in response to the January 2020 statement of the case for the issue of entitlement to an effective date earlier than April 14, 2014 for the grant of service connection for Parkinson's disease. Therefore, there is no pending appeal for these issues, and they are not before the Board. INCREASED RATING 1. Entitlement to an evaluation in excess of 70 percent for schizophrenia 2. Entitlement to a TDIU prior to April 14, 2014 Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. 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). However, consideration also must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: 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; associated 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 worklike setting); and inability to establish and maintain effective relationships warrants a 70 percent rating. A 100 percent rating is provided for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behaviour; 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. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign for psychiatric disabilities, the Board's "primary consideration" is the Veteran's demonstrated symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim of entitlement to a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). A TDIU 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. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the purpose of determining whether there is one disability evaluated at 60 percent, or one disability evaluated at 40 percent where the combined rating of all service-connected disabilities is 70 percent or greater, disabilities resulting from a common etiology will be considered as "one disability." Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. See 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Reviewing the evidence or record, it was noted at July 2012 VA treatment that the postal service was not going to relocate the post office where the Veteran worked and that he would continue to work there for the next two years. The Veteran said that his mood was stable, and he denied problems with depression, anxiety, anger management, and concentration. He said that he liked spending time with his wife and watching baseball games on television. Energy and sleep were adequate to meet all of the Veteran's needs. The Veteran said that he had started again at his full-time job the prior week and that his job performance was satisfactory. On examination the Veteran was coherent and polite, and he denied suicidal and homicidal ideation. The Veteran reported seeing flashes on the sides of his vision that he knew were not real, and otherwise did not report hallucinations. At February 2013 VA treatment the Veteran reported that he had enjoyed going out to lunch with his whole family the past weekend. He said his mood was generally stable and he denied problems with concentration. The Veteran had a VA examination in February 2013. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported feeling slightly "manicky." There was slight racing of thoughts, fast speech, distractibility, difficulty sleeping, and increased irritability. The Veteran denied suicidal and homicidal thoughts but thought he was more paranoid. He had recently gone to a casino and felt that someone was following him. His work had been stressful, but he was able to maintain it. On examination the Veteran was oriented to person, place, time, and situation, and his speech had a normal rate and rhythm. Insight was fair and there was difficulty with concentration and focus. Thought process was logical and affect was full and appropriate to content. The Veteran reported that he injured a knee at work in March 2012. He was placed on light duty, was then off a month after surgery, and then returned to work at reduced hours. The Veteran had started working full time again a couple weeks before. The Veteran reported good relationships with his family. He said that he had taken his medication consistently since a "psychotic break in 1997." The examiner noted that the Veteran's symptoms were suspiciousness, difficulty in being able to establish and maintain effective work and social relationships, difficulty adapting to stressful circumstances, including work or a worklike setting, and an intermittent inability to be able to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran reported periods of mania and depression. He said that during periods of mania it was hard to slow his thoughts down and that he had recently been more argumentative with his wife. During a recent period of depression, he only showered every three to four days when reminded by his wife and had anhedonia, loss of energy, feelings of worthlessness, and poor appetite. The Veteran saw flashes out of the corners of his eyes of things that he knew were not really there. He said the last period with no mania or depression was the prior summer or fall. The examiner felt that the symptoms were due to the service-connected schizophrenia. The Veteran was oriented to person, place, time, and situation at April 2013 VA psychiatric treatment. Speech was normal and mood euthymic. Affect was blunted, and thought process was normal. The Veteran denied difficulty with concentration or hallucinations. He did not express suicidal ideations. In September 2013 the Veteran had a psychiatric examination as part of a Social Security examination. It was noted that he was seeking a disability retirement, and he said he could not keep working due to health problems. The examiner noted that the Veteran was in contact with reality but that his mood was low. His attitude was cooperative, and insight and judgment were intact. He was noted to have good grooming and hygiene. The Veteran was oriented to time, person, and place. The examiner felt that the Veteran's mood and health issues interfered with his ability to function to his full potential. At March 2014 VA treatment the Veteran reported that his mood had been "pretty good," and he rated it as seven out of ten. It was noted that he retired in October 2013. The Veteran was oriented to person, place, time, and situation, and insight was good. He denied delusions or hallucinations or difficulty with concentration. The Veteran reported manic symptoms including not sleeping and irritability at July 2014 VA treatment. At August 2014 VA treatment he reported being oriented to person, place, time, and situation. He denied problems with focus or concentration, delusions, hallucinations, or suicidal or homicidal ideation. In May 2015, a private psychologist wrote that the Veteran was unable to work due to a combination of factors, one of which was schizophrenia, which more than likely than not impaired the Veteran from being able to return to work. The Veteran was considered permanently and totally disabled from any form of competitive gainful employment due to schizophrenia. The psychologist noted that the Veteran said he stopped working in 2013 due to chronic knee pain and that this injury aggravated the Veteran's schizophrenia. At June 2015 treatment the Veteran reported being paranoid and suspicious of others since his prior treatment. He was anxious around crowds and reported hallucinations of spiders. In July 2015 the Veteran's wife reported to a VA psychiatric provider that she was concerned about his ongoing depression and lack of motivation. At August 2015 VA treatment the Veteran reported feeling more "manicky," which he said mean he was sleeping less and talking more. On examination in June, July and August 2015 the Veteran was fully oriented, and insight and judgment were good. Speech, thought process, concentration, and thought content were within normal limits. Suicidal or homicidal ideation were denied. In September 2015 a vocational expert opined that the Veteran was totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected schizophrenia, orthostatic hypotension, inflammation of the hard palate, taste impairment associated with schizophrenia, and hand tremors associated with schizophrenia, and that the record supported this "as far back as the date of filing." The Veteran said at January 2016 VA treatment that he had felt more tired and fatigued since November and was depressed during the day. However, he denied feeling worthless, hopeless, or helpless, hallucinations, thoughts of suicide or homicide, or manic symptoms. The Veteran was noted to be fully oriented and overtly cognitively intact. At April 2016 VA treatment the Veteran denied suicidal and homicidal thoughts, intentions, and plans. His mood was a little down, but he looked forward to moving the next month to be closer to his grandchildren. The Veteran was fully oriented and overtly cognitively intact. He denied suicidal and homicidal thoughts, ideations, intentions, and plans. The Veteran did not have hallucinations, and speech was considered normal. At August 2016 VA treatment the Veteran was oriented to person, place, time, and situation. His attitude was pleasant and cooperative. The Veteran's wife reported that he had some short-term memory issues. Insight and judgment were good. In December 2016 the Veteran wrote on a TDIU claims form that he stopped working as a maintenance mechanic at the postal service in October 2013. His level of education was high school. On the section of the form labeled remarks, the Veteran wrote AFib, side effects of Parkinson's, knee issues, and bipolar. The Veteran said at May 2017 VA treatment that he wanted to keep his mood swings, depression, mania, and psychotic symptoms under control. On examination thought process was linear and goal directed, and there was no evidence of "a flight of ideas." Thought content showed on evidence of paranoia or delusions, and he denied suicidal or homicidal ideations or plans. Judgment and insight were fair, and the Veteran was oriented to time, place, and person. Subsequent treatment records show that he has continued to be oriented to time, place, and person with no suicidal or homicidal ideation and no evidence of delusions. He had inpatient VA treatment in July 2017 due to a manic episode. At July 2018 VA treatment the Veteran said that he was thinking clearer and was no longer going out to shop in the middle of the night. The Veteran had an examination arranged through VA in November 2020. The examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. It was noted that the Veteran had significant social impairment due to schizoaffective disorder and that he spends money impulsively during manic episodes. He had been banned from a local gas station a few months before for behavior he thought was helpful but that was perceived as intrusive and inappropriate. Symptoms were depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, impairment of short and longterm memory, abnormal speech, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control. The Veteran was noted to be casually addressed and appropriately groomed with good eye contact and appropriate social skills. He was polite, open, and cooperative. Thought process was mildly circumstantial but logical, and he had excellent insight into his mental illness. There was no evidence of hallucinations or delusional thinking, and the Veteran denied current suicidal or homicidal ideation. The examiner wrote that the Veteran did not display significant social impairment due to his mental disorder. At December 2020 VA treatment the Veteran reported having manic symptoms every six months. In recent years, he had had more manic symptoms relative to depressive symptoms. The Veteran said he had anxiety and worried that people talked about him. He denied current hallucinations or delusions or suicidal or homicidal ideation. The Veteran does not qualify for a 100 percent schedular evaluation, the next highest available, which requires total occupational and social impairment. See 38 C.F.R. § 4.130, Diagnostic Codes 9411-9434. The record does not indicate that he has been disoriented to time, place, and person. Furthermore, the record shows that thought content has been appropriate. The Veteran has consistently denied suicidal and homicidal ideation or intent, and he has generally maintained activities of daily living except when he said at the February 2013 examination that his wife had to remind him to shower during an episode of depression. The February examiner noted an intermittent inability to perform activities of daily living. The Veteran occasionally reported visual hallucinations that he understood to be reality, and he otherwise had hallucinations or psychosis. His interactions with others have generally been appropriate, although he occasionally makes others uncomfortable, such as at the local gas station. Furthermore, memory loss has been mild. Although the Veteran has some symptoms associated with a 100 percent rating such as intermittent inability to perform activities of daily living, the record as a whole does not show total occupational and social impairment. In light of the holding in Hart, supra, the Board has considered whether the Veteran is entitled to "staged" ratings for his service-connected schizophrenia, as the Court indicated can be done in this type of case. Based upon the record, the Board finds that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. It is also noted that the record does not show worsening of schizophrenia within one year prior to the October 2012 claim for an increased rating. See 38 C.F.R. § 3.400(o). Regarding entitlement to a TDIU prior to April 14, 2014, service connection was in effect for schizophrenia, rated 70 percent; orthostatic hypotension, rated 10 percent; inflammation of the hard palate, rated noncompensable; taste impairment, rated noncompensable; and tremors of the hands, rated noncompensable. The combined rating was 70 percent. Since the combined rating is at least 70 percent with one disability rated at least 40 percent, the Veteran meets the schedular requirements of 38 C.F.R. § 4.16(a). By the Veteran's own reports, including the December 2016 TDIU claims form, he worked in his job with the postal service until October 2013. Therefore, he cannot be eligible for a TDIU prior to that date. A TDIU is currently in effect from April 14, 2014. Regarding the period from October 2013 to April 2014, the record does not show that the Veteran was unable to maintain substantially gainful employment due to the disabilities for which service connection was then in effect. Probative value cannot be given to the opinion of the September 2015 a vocational expert opined that the Veteran was totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected schizophrenia, orthostatic hypotension, inflammation of the hard palate, taste impairment associated with schizophrenia, and hand tremors associated with schizophrenia, and that the record supported this "as far back as the date of filing." It is not clear what date the vocational expert was referring to in relation to the "date of filing." However, the record shows the Veteran continued to maintain employment for a year after the increased rating claim was filed in October 2012. Therefore, it cannot be said that the Veteran was precluded from employment "from the date of the claim." In May 2015, a private psychologist wrote that the Veteran was unable to work due to a combination of factors, one of which was schizophrenia, which more than likely than not impaired the Veteran from being able to return to work. The Veteran was considered permanently and totally disabled from any form of competitive gainful employment due to schizophrenia. It not clear if the psychologist was referring to the period prior to April 14, 2014, which is the relevant period for the claim for an earlier effective date of a TDIU. The private psychologist noted that the Veteran said he stopped working in 2013 due to chronic knee pain, and that this injury aggravated the Veteran's schizophrenia. At the February 2013 VA examination the Veteran discussed his knee injury in regard to his difficulty working, and in September 2013 the Veteran said he could not work due to health problems without specifying the service-connected schizophrenia. The opinions discussed above that the Veteran cannot work due to service-connected schizophrenia, to the extent that they are for the period prior to April 14, 2014, are not consistent with the record as a whole, including the Veteran's contemporaneous reports, that other health problems were why he could not work at that time. Therefore, they are not probative. Because the evidence preponderates against the claims for an evaluation in excess of 70 percent for schizophrenia, and to a TDIU prior to April 14, 2014, the benefit of the doubt doctrine is inapplicable, and the claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. SERVICE CONNECTION 3. Entitlement to service connection for left knee degenerative joint disease, to include as secondary to medication taken for schizophrenia 4. Entitlement to service connection for right knee degenerative joint disease, to include as secondary to medication taken for schizophrenia Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection will also be presumed for certain chronic diseases, including arthritis, if manifest to a compensable degree within one year after discharge from service. 38 C.F.R. §§ 3.307, 3.309. Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). In order for the presumption to apply, the claimant must be a veteran with 90 days of active, continuous service. 38 C.F.R. § 3.307(a)(1). In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The service treatment records do not show complaints, treatment, or diagnoses related to the knees. At March 2017 VA treatment the Veteran complained of worsening bilateral knee pain. It was noted that he had been receiving bilateral knee steroid injections, and a diagnosis of chronic osteoarthritis of the knees was noted. The Veteran had a VA examination in July 2019 at which she was diagnosed with bilateral knee osteoarthritis with meniscus tears, status post arthroscopy. The date of diagnosis was 2010, and the Veteran said that the onset of knee pain was around 2010 without trauma. The Veteran attributed his bilateral knee disabilities to weight gain due to taking Depakote for his service-connected schizophrenia. He started taking Depakote 15 years before. The examiner opined that the bilateral knee disabilities were not incurred in or caused by an in-service event or injury. The rationale was that the onset of bilateral knee pain was in the early 2010s, the service treatment records do not show chronic or recurrent problems with the knees, and the record does not show the onset of osteoarthritis in the knees within a year of service. The examiner also opined that bilateral knee osteoarthritis was less likely than not proximately due to or the result of medication for the service-connected schizophrenia. The rationale was that weight gain was the most likely cause of the advanced bilateral knee osteoarthritis and degenerative meniscus tear. The examiner wrote that Depakote is a mood stabilizer used for treating schizophrenia and is commonly associated with weight gain. However, the Veteran's weight gain was likely multifactorial. The Veteran was obese prior to starting Depakote and gained significant weight since starting on it. Factors leading to obesity prior to starting Depakote, including diet and lifestyle choices, could not be discounted. The Veteran's weight gain could only be attributed to Depakote to a minor degree. The examiner concluded that it was less likely as not that treatment for schizophrenia had a significant impact on the development of osteoarthritis of the knees. The VA examiner's opinion indicates that bilateral osteoarthritis of the knees has been aggravated from taking Depakote for the service-connected schizophrenia. By stating that treatment for schizophrenia did not have a "significant impact" on the development of osteoarthritis, the examiner was implying that the schizophrenia treatment did have some impact. The examiner noted that the Veteran gained a significant amount of weight after starting to take Depakote, and the examiner's statement indicates that the Veteran's weight is related to osteoarthritis of the knees. The record is at least in equipoise regarding whether the Veteran bilateral osteoarthritis of the knees was aggravated by the medication Depakote taken for the service-connected schizophrenia. When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; 38 C.F.R. § 3.102. Service connection for left and right osteoarthritis of the knees is therefore warranted. (continued on next page) EFFECTIVE DATE 5. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for urinary incontinence as a complication of Parkinson's disease 6. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for a left upper extremity tremor as a complication of Parkinson's disease 7. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for a right upper extremity tremor as a complication of Parkinson's disease 8. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left masked facies as a complication of Parkinson's disease 9. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right masked facies as a complication of Parkinson's disease 10. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left tardive dyskinesia as a complication of Parkinson's disease 11. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right tardive dyskinesia as a complication of Parkinson's disease 12. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left bradykinesia as a complication of Parkinson's disease 13. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right bradykinesia as a complication of Parkinson's disease 14. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for left sided stooped posture as a complication of Parkinson's disease 15. Entitlement to an earlier effective date than April 14, 2014, for the grant of service connection for right sided stooped posture as a complication of Parkinson's disease The effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). Generally, the effective date of an award of an increased evaluation is the date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). For disability compensation, the effective date of an award shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date otherwise, the date of receipt of claim. 38 C.F.R. § 3.400(o)(2). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or her representative, may be considered an informal claim. Such informal claim must identify the benefit sought by the claimant. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). In addition, a communication received from a service organization, an attorney, or an agent may not be accepted as an informal claim if a power of attorney was not executed at the time the communication was written. Service connection for Parkinson's disease is in effect from April 14, 2014. Therefore, an earlier effective date than April 14, 2014, cannot be granted for complications of Parkinson's disease since service connection was not in effect for the underlying disability. The claims for earlier effective dates than April 14, 2014, for the grant of service connection must therefore be denied. REASONS FOR REMAND 1. Entitlement to an initial evaluation in excess of 20 percent for left sided bradykinesia as a complication of Parkinson's disease is remanded. 2. Entitlement to an initial evaluation in excess of 20 percent for right sided bradykinesia as a complication of Parkinson's disease is remanded. 3. Entitlement to an initial evaluation in excess of 10 percent for left sided stooped posture as a complication of Parkinson's disease is remanded. 4. Entitlement to an initial disability evaluation in excess of 10 percent for right sided stooped posture as a complication of Parkinson's disease is remanded. 5. Entitlement to an initial compensable evaluation for urinary incontinence as a complication of Parkinson's disease is remanded. 6. Entitlement to an initial evaluation in excess of 30 percent for a right sided upper extremity tremor as a complication of Parkinson's disease is remanded. 7. Entitlement to an initial evaluation in excess of 20 percent for a left sided upper extremity tremor as a complication of Parkinson's disease is remanded. 8. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 20 percent from that date, for left sided masked facies as a complication of Parkinson's disease is remanded. 9. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 20 percent from that date, for right sided masked facies as a complication of Parkinson's disease is remanded. 10. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 10 percent from that date, for left sided tardive dyskinesia as a complication of Parkinson's disease is remanded. 11. Entitlement to an initial compensable evaluation prior to September 27, 2016, and in excess of 10 percent from that date, for right sided tardive dyskinesia as a complication of Parkinson's disease is remanded. In September 2018 the Board remanded the above increased rating issues as intertwined with the earlier effective date issues now before the Board. The Veteran last had a VA examination related to the symptoms of Parkinson's disease in August 2016. In light of the state of the record, the Board finds that the Veteran must be afforded contemporaneous VA examinations to assess the current severity of bilateral bradykinesia, bilateral stooped posture, urinary incontinence, bilateral upper extremity tremors, bilateral masked facies, and bilateral tardive dyskinesia. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran's pertinent medical history). VA treatment records to December 2020 have been associated with the claims file. The RO should attempt to obtain all relevant VA treatment records dated from December 2020 to the present, while the claim is in remand status. Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain VA treatment records from December 2020 to the present. 2. Thereafter, schedule the Veteran for appropriate VA examinations in order to determine the nature and severity of the Veteran's bilateral bradykinesia, bilateral stooped posture, urinary incontinence, bilateral upper extremity tremors, bilateral masked facies, and bilateral tardive dyskinesia. The claims file must be made available to the examiner for review prior to the examination. All necessary tests should be conducted, and the examiner(s) should review the results of any testing prior to completion of the report. All opinions must be supported by a complete rationale. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Scott Shoreman, 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.