Citation Nr: 21041617 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 18-19 322 DATE: July 9, 2021 ORDER 1. Entitlement to a disability rating greater than 50 percent for post-traumatic stress disorder (PTSD) beginning June 26, 2012 to July 22, 2020, excluding the period from March 28, 2017 through May 31, 2017 during which the Veteran was entitled to a temporary increased rating due to hospitalization, is denied. 2. Entitlement to a disability rating greater than 70 percent disabling for PTSD beginning July 23, 2020 is denied. REMANDED Entitlement to service connection for a glucose-6-phosphate dehydrogenase deficiency (G-6PD) is remanded. FINDINGS OF FACT 1. The evidence shows that for the period beginning June 26, 2012 to July 22, 2020, excluding the period from March 28, 2017 through May 31, 2017 during which the Veteran was entitled to a temporary increased rating due to hospitalization, the Veteran's PTSD was most closely manifested by symptoms of occupational and social impairment with reduced reliability and productivity; without more severe manifestations of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. Beginning July 23, 2020 the evidence shows that the Veteran's PTSD is most closely manifested by symptoms of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; without more severe manifestations of total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for an increased PTSD disability rating greater than 50 percent, beginning June 26, 2012 to July 22, 2020, excluding the period during which the Veteran was entitled to a temporary increased rating due to hospitalization, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for an increased PTSD disability rating greater than 70 percent, beginning July 23, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from July 1968 to August 1971. He served two tours in the Republic of Vietnam, from December 1968 to December 1969, and again from January 1970 to December 1970. This matter returns to the Board of Veterans' Appeals (Board) after the Board's February 2020 remand (Board Remand) of the Veteran's appeal of the August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which is the agency of original jurisdiction (AOJ). In this rating decision, the AOJ granted the Veteran's claim for entitlement to service connection for PTSD at a 50 percent rating level but denied the clam related to G-6PD. The Veteran filed a timely appeal seeking a higher PTSD disability rating and to secure an award of service connection for his G-6PD. In a September 2020 rating decision, the Veteran was granted an increased PTSD disability rating of 70 percent, effective July 23, 2020. However, as this does not constitute a complete grant of the benefits sought, the matter remains on appeal before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). The Board notes the Veteran was assigned a temporary evaluation of 100 percent disabling for PTSD, effective March 28, 2017, due to hospitalization over 21 days for treatment related to this PTSD. Thereafter, his evaluation of 50 percent was resumed beginning June 1, 2017, which is the first of the month in which he was discharged. The Board's decision herein does not alter the temporary 100 percent rating due to hospitalization as a matter of law. 38 C.F.R. § 4.29. The Board also notes that the February 2020 Board Remand requested that the AOJ conduct additional development related to both his PTSD and G-6PD claims. The remand instructions related to PTSD directed the AOJ to request the Veteran complete a form to authorize the release of his records from the P.G.C.Vet Center on Malcolm Road (Vet Center), where the Veteran received group PTSD counselling. Thereafter the Veteran was to be scheduled for a new VA psychological evaluation related to his current PTSD symptoms. The Veteran and his representative were each sent a copy of the February 2020 Board Remand itself which contained the remand instructions. VA did send to the Veteran and his representative each a copy of the required form, along with instructions in a letter dated March 2, 2020. The Veteran did not respond. VA's duty to assist claimants is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("[t]he duty to assist is not always a one-way street."). Nonetheless, on February 28, 2020, VA received copies of the Veteran's VA treatment records which did include notes from his VA mental health provider, Dr. S.C., related to his consultations and noted his treatment at the Vet Center on Malcolm Road. The Veteran was provided the follow-up VA psychological evaluation related to this PTSD in June 2020, from which he was granted an increased rating for PTSD to 70 percent. Only a 100 percent total disability rating is higher. The Veteran was also provided a second post-remand VA psychological evaluation related to this PTSD in May 2021, which provided the basis for his 70 percent PTSD rating to be continued, as well as to grant to him the assignment of a total disability rating based on individual unemployability (TDIU), which confers on him a 100 percent disable rating, effective May 5, 2021. See May 2021 Rating Decision. In the May 2021 Rating Decision, the Veteran's disability was also determined to be total and permanent, effective May 5, 2021. See May 13, 2021 VA Notification Letter. Thus, records related to the Veteran's treatment at the Vet Center were received, and he was subsequently granted increased disability ratings related to his PTSD. After review of the record, the Board is satisfied that there was substantial compliance with the remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (only "substantial" rather than strict compliance with the Board's remand directives is required under Stegall). The Veteran appeared for a Board Hearing with the undersigned Veteran's Law Judge (VLJ) in January 2020, and a copy of the transcript for that hearing has been associated with the Veteran's claims file. The Veteran was accompanied by his then appointed representative, along with his wife and sister, both of whom provided testimony in support of the Veteran's claims. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 38 U.S.C. § 1155. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes (DCs). 38 U.S.C. § 1155, 38 C.F.R. § 4.27. 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. 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 benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in the condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). 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). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. At the beginning of the appeal period, the Veteran's PTSD was rated at a 50 percent disabling level. Under the General Rating Formula For Mental Disorders, to include PTSD, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where there is 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 (ADLs) (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, 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(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In evaluating the level of disability, it is also necessary to evaluate such from the point of view of a Veteran working or seeking work. 38 C.F.R. § 4.2. The Evidence of Record. The Veteran asserts that his PTSD symptoms are more severe than what is compensated for in his initial 50 percent disability rating, which is effective June 26, 2012. This is the date on which VA received the Veteran's initial claim for this disability. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The Veteran's initial PTSD disability rating was based on findings that the Veteran had a current diagnosis of PTSD with anxiety, depression, and insomnia; with symptoms of difficulty in adapting to stressful circumstances; disturbances of motivation and mood; flattened affect; difficulty in establishing and maintaining effective work and social relationships; chronic sleep impairment; anxiety; suspiciousness; depressed mood; and mild memory loss. His level of occupational and social impairment was noted to consist of occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). See August 2014 Rating Decision and July 2014 VA Initial PTSD DBQ. The Veteran was noted to not be working at this time, having retired in 2010 after working approximately 22 years for his only employer since he separated from the military in 1988. After his 2017 hospitalization, the Veteran's 50 percent PTSD disability rating was restored based on findings of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. See June 2017 Rating Decision, and Discharge Summary, East Orange VA Medical Center, for inpatient stay March 28, 2017 to May 16, 2017, received by VA on May 24, 2017. The Board notes that the Veteran's case has a very long, complex, and extensive record of evidence, both in volume of documents and treatment encounters, which cannot feasibly be detailed in its entirety in this decision. The Board has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the issues in the claim and this appeal. The Veteran's first VA psychological evaluation related to his claim for compensation benefits was conducted in May 2015. The VA examiner confirmed the Veteran's diagnosis of PTSD which was described as "largely marginal" with his symptoms manifesting only infrequently and to have occurred in the past, not then currently. The level of occupational and social impairment was described as due to mild or transient symptoms which decrease work efficiency and his ability to perform occupational tasks only during periods of significant stress and/or with his symptoms controlled by medication. His symptoms were noted to include chronic sleep impairment, disturbances of motivation and mood, and an inability to establish and maintain effective relationships. Concerning his sleep impairment, he was noted to have occasional nightmares (once per month) as well as a diagnosis of sleep apnea for which he reported problems with his CPAP mask. He denied both current and past suicidal thoughts, ideation, plans or intent. The Veteran described his relationships with his wife and children to be good, and he had regular interactions with his family. His work history was only noted that he was not currently working, as he retired from his last job in 2010 for which he received a pension. The Veteran stated that he can be isolated but is not bothered by crowds and that since retirement he doesn't have a lot to do. He denies depression, suicidal ideation, anxiety, panic, and vegetative signs. In his final remarks, the VA examiner noted mild symptoms that were somewhat transient. Based at least in part on this evaluation, the Veteran was granted service connection for his PTSD, at an initial 50 percent disability rating. See, August 2014 Rating Decision. After the Board's February 2020 remand, the Veteran was provided a VA psychological evaluation in July 2020 in which his level of is occupational and social impairment was noted to be deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms noted as: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; disturbances of 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 intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. However, there were not noted symptoms usually associated with either a 70 or 100 percent severity level of disability rating. The Veteran was noted to have a robust social support network, including his wife, sister, and numerous children, some of whom live with his wife and him, and that he also uses the local Veteran Center as a social support system. In fact, the Veteran was escorted to his evaluation by his sister/ care giver with whom the examiner met and interviewed. She indicated she is most worried about the Veteran's sensitivity to everything that is going on around him which seemed to be intensifying and his depression which "flip flops" sometimes. She called him every day and stated her main concern with his mental state is signs of forgetfulness. She also stated that he still drives. Regarding his occupational and educational history, the examiner noted that the Veteran wanted to work longer but stated that it seemed like the whole place was closing in on him. His highest education level is one year of college. This VA psychological evaluation was part of the basis for the RO assigning him an increased disability rating of 70 percent for his PTSD. See, September 2020 Rating Decision. In May 2021, the Veteran was provided another VA psychological evaluation in which the Veteran's level of is occupational and social impairment was again noted to be deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to the same symptoms noted in the July 2020 VA psychological evaluation. Similarly, there was no indication of the Veteran exhibiting symptoms typically associated with either a 70 or 100 percent PTSD disability rating. The Veteran's sister and wife were identified as his caregivers, and no change in his social support network from the previous evaluation was noted. In his occupational history, the examiner noted that sometimes he goes into his back yard to cut down and take care of bamboo trees, and that his daily his routine includes oversleeping most of the time but he does the dishes and laundry and he helps with cleaning at the house. This VA psychological evaluation was part of the basis for the Veteran's award of TDIU, though it did not support an increased rating of 100 percent disabled due to his PTSD. See, May 2021 Rating Decision. VA Treatment records. As noted above, the Veteran's record contains a very large number of encounter notes and pages of documents. These include records of the Veteran's encounters and treatment with Dr. S.C. his primary VA mental health provider who also noted and monitored his group therapy treatment and progress at the Vet Center on Malcom Road. The select VA treatment encounter notes referenced below represent and capture the Veteran's overall condition for the period of time noted, as well as any progression or continuation of various symptoms. The Veteran's initial treatment for mental health issues began in November 2013, though it was noted he had a history of existing PTSD for which he went to his local Veteran's Center for group PTSD therapy. He was referred to VA mental health providers after which he received medications and regular individual mental health counseling through VA. In a November 20, 2013 initial VA primary care note the Veteran stated that he had PTSD for over 40 years with a relapse to more severe symptoms since his retirement. The Veteran indicated that he was no longer distracted from his PTSD symptoms since he is not working, and reports feeling guilt about things he did in Vietnam. He also stated that his parents made his see a psychiatrist upon his return home from his first tour in Vietnam, but no diagnosis was stated, nor follow-up treatment identified. He did then completed a second tour in Vietnam being motivated to complete the job. He continued to receive psychological treatment until his hospitalization for PTSD treatment. The Veteran began treatment with Dr. S.C. in June 2015, his VA psychiatrist, who was his mental health treatment coordinator. He suffered in incident in June 2016 where he was assaulted and robbed and suffered physical injury including a concussion. His symptoms, including anxiety and avoidance of crowds, increased after that incident, and in January 2017 he was advised of and asked to begin the PTSD Residential Rehabilitation Program at Lyons, NJ. He was accepted and began the program in March 2017. An assessment note during his hospital stay recorded that the Veteran does not complain of severe emotional distress, severe anxiety, pain symptoms, helplessness, insomnia, obsessions, intoxications, hallucinations or suicidal or homicidal ideation or intent. He was discharged May 16, 2017, after which he continued his VA treatment under the direction of Dr. S.C. After discharge from his hospital treatment, the Veteran was given a VA neuropsychology consultation with psychologist Dr. L.W. on August 22, 2017 regarding complaints of memory loss following the June 2016 hear trauma. Dr. L.W. noted the assault incident which was apparently shortly thereafter followed with a minor motor vehicle accident. The Veteran indicated a history of anger but now gets frustrated more frequently over small issues, including misplacing objects of forgetting to complete tasks. His issues were also impacted by his sleep apnea. Dr. L.W. stated that the Veteran's presentation was consistent with a history of chronic mild PTSD and sleep apnea. In a February 19, 2019 VA Mental Health Note it was recorded that the Veteran's mood has been stable other than feeling down in the context of attending five funerals in his family. His son, daughter in law, and two grandchildren moved in with the Veteran not reporting any problems except that his grandchildren are a "handful." In a February 18,2020 VA outpatient note, the Veteran stated his only problem with his wife is that they will often get into an argument. These treatment records show that the Veteran was continually on prescribed medication for his mental health issues prior to and throughout the appeal period; and that he consistently maintained that he took these medications when and how prescribed with only a few exceptions; and, notably, that he actively engaged with his treating medical providers in describing their impact and efforts to adjust the medications to optimize their effectiveness. Veteran's statements, hearing testimony, and "Buddy" statements. The Veteran submitted several written statements in support of his clam, in as well as his Board Hearing testimony. Additionally, written "Buddy" statements were received from the Veteran's wife, sister, brother, and friend of many years, I.T. I.T. stated that he has known the Veteran and his wife for many years and has been there when all of his children were born and that his family and the Veteran's family are very close. While these statements do support the Veteran's claim that he experiences PTSD, and that numerous symptoms have caused concern for each individual, including his experiencing nightmares, sleep impairment, irritability, lack of energy and motivation, and forgetfulness, as well as how the Veteran's symptoms have had more impact on him over time. However, the Board finds that these statements do not report symptoms which are typically associated with PTSD severity associated with disability ratings of 70 or 100 percent. These statements reaffirm that the Veteran has a strong social support system also with dedicated family support and relationships, including his status as husband, brother, and father. Analysis. After reviewing the evidence of record the Board finds that an increase in the Veteran's current PTSD disability ratings, and their respective effective dates, is not warranted. 1. Entitlement to a disability rating greater than 50 percent for PTSD beginning June 26, 2012 to July 22, 2020. The Board finds that during the period beginning June 26, 2012 to July 22, 2020, excluding the period from March 28, 2017 through May 31, 2017 during which the Veteran was entitled to a temporary increased hospitalization rating, the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission most closely correspond to occupational and social impairment with reduced reliability and productivity which equates to a 50 percent disability rating, but no more. The Veteran was not noted to have regularly exhibited symptoms such as suicidal ideation he was consistently noted not to have suicidal or homicidal ideation or intent; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively though he did exhibit depressive symptoms they were not to the level of impairment to limit his abilities; impaired impulse control (such as unprovoked irritability with periods of violence there was a lack of violence recorded or expressed as significant concern to his family members or mental health providers); spatial disorientation; neglect of personal appearance and hygiene; and inability to establish and maintain effective relationships his family relationships have consistently been very strong and engaged, as well as a strong social connection with his PTSD support group. While the Veteran was noted to have some difficulty in adapting to stressful circumstances (including work or a work-like setting), these symptoms were not addressed as primary concerns of deficiencies addressed in his treatment, except for his treatment period at the VA Lyons, NJ facility. This includes the fact that he claims to have retired from his job as he felt things were closing in on him. This particular aspect was not routinely discussed with his mental health providers. Nor was there much discussion of his trying to return to work. The Board does find the Veteran, as well as those who submitted testimony on his behalf, to be competent and credible to what they observed of his PTSD symptoms and their impact. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). However, none of these lay witnesses provided testimony which described the Veteran's symptoms or their specific concerns to raise his level of severity to 70 percent disabling rating levels. Based on the above, the Board finds that an award greater than 50 percent disabling for PTSD for this period is not warranted. In reaching this conclusion, 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 claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). The claim for an increased disability rating for PTSD beginning June 26, 2012 to July 22, 2020, excluding the period of his hospitalization, is denied. 2. Entitlement to a disability rating greater than 70 percent disabling for PTSD beginning July 23, 2020 is denied. At no time during the appeal period did the Veteran exhibit symptoms which caused total occupational and social impairment which would entitle him to a 100 percent schedular disability rating for PTSD. 38 C.F.R. § 4.130, DC 9411. The Board is aware that the Veteran has been assigned an award of TDIU, effective May 5, 2021, due to his service-connected PTSD symptoms and that this provides him the benefit of a 100 percent disability rating. See May 2021 Rating Decision; See also 38 C.F.R. § 4.16. However, the rating requiems to establish entitlement to an assignment of TDIU and a 100 percent total disability schedular rating for PTSD are quite different. TDIU is based on an inability to obtain or maintain substantially gainful employment. Id. Whereas the 100 percent schedular rating for PTSD is based on the Veteran's PTSD symptoms. 38 C.F.R. § 4.130, DC 9411. The Board finds that the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission do not support a 100 percent disability rating. As noted above, this determination does not impact the Veterans temporary 100 percent rating for his period of hospitalization, which is not disturbed. During the appeal period, the Veteran's PTSD symptoms were not noted to constitute gross impairment in thought processes or communication; that he had persistent delusions or hallucinations, in most instances it was noted he denied audio and visual hallucinations; grossly inappropriate behavior; to be a persistent danger of hurting self or others, consistently he was noted to not have either suicidal or homicidal thoughts or intent, nor were there reports of him being a danger to others; that he exhibited intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and there is no indication that he exhibited routine disorientation to time or place or memory loss for names of close relatives, own occupation, or own name. The Board also finds significant the Veteran's longstanding very close and supportive relationships with the members of his family and his PTSD support group. This include his marriage, close relationship with his sister, that both his wife and sister are engaged caregivers who accompanied the Veteran to his VA psychological evaluations. At various times he has lived with his son and his family, and the Veteran enjoys the company of his grandchildren. Based on the above, the Board finds that an award of a 100 percent disability rating for PTSD is not warranted at any time during the appeal period. In reaching this conclusion, 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 claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). The claim for an increased disability rating greater than 70 percent for PTSD is denied. REASONS FOR REMAND 1. Entitlement to service connection for a glucose-6-phosphate dehydrogenase deficiency (G-6PD) is remanded. The Veteran contends his current G-6PD disability is related to his military service. Specifically, the Veteran initially claimed this condition was caused by or aggravated by his taking malaria pills while he was in Vietnam. Later, he asserted this condition was caused by or aggravated when he received blood transfusions of blood with a wrong or incompatible blood type, different than his. He claims his military issued dog tags indicated an incorrect blood type, which is also incorrectly noted on his DD-214 (though that is after the claimed incident). See Veteran's written statement, September 30,2020; Report of General Information from the Veteran, September 21, 2020; and Hearing Transcript, pages 16-17. After the February 2020 Board Remand, the Veteran was provided a VA examination for this condition. In the August 2020 VA examination report the examiner noted his diagnosis of G-6PD in 1970. Also noted was the Veteran's assertion that his condition was from taking DAPSON malaria medicine and that he received 2 blood transfusions while in service, but he did state that he was given blood of the wrong or an incompatible type. The VA examiner was asked to opine whether the Veteran's G-6PD was at least as likely as not related to an in-service injury, event, or disease, including taking malaria medication. The VA examiner opined that it was not, based on the rationale that G-6PD is a genetic disorder that results from mutations in the G-6PD gene and there is no substantial medical evidence or literature to show that malaria medication can cause G-6PD. A Veteran is presumed to have been sound upon entry into active duty service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). In other words, "[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). However, congenital or developmental defects are not diseases or injuries within the meaning of applicable VA statutes and regulations. 38 C.F.R. §§ 3.303(c), 4.9. Therefore, where a Veteran seeks service connection for a congenital or developmental condition, the Board must first determine if the congenital or developmental condition is a defect or disease. If the congenital or developmental condition is a "defect" (a structural or inherent abnormality which is more or less static in nature), the presumption of soundness does not apply and service connection must be denied unless the evidence establishes that the condition was aggravated beyond it normal progression or that a disability due to disease or injury that was incurred in service is superimposed on the congenital defect. See VAOPGCPREC 82-90 (1990); see also 38 U.S.C. §§ 1110, 1111, 1132; see also 38 C.F.R. § 3.303(c); see also Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995). Here the VA examiner indicated that the Veteran's claimed condition is a genetic disorder but did not specify if it is a defect or disease. Nor was there an opinion whether the condition was aggravated beyond it normal progression or that a disability due to disease or injury that was incurred in service is superimposed on the congenital defect. Therefore, the Board must remand the matter to obtain an addendum medial opinion on these issues. Before the addendum opinion is rendered, the Veteran is to be afforded an opportunity to submit additional evidence to support his claim, including that the blood given to him during his in-service blood transfusions were of an incompatible blood type. Kutscherousky v. West, 12 Vet. App. 369, 372-73 (1999) (per curiam order) (A Veteran is permitted to submit additional evidence or argument to support his claim). The matters are REMANDED for the following action: 1. Contact the Veteran to afford him an opportunity to provide any additional records and arguments which are related to his claimed assertion that while he was in the service, he was given transfusions with blood of the wrong blood type, and that if so, that this would cause or impact his G-6PD condition, and any other evidence related to his G-6PD condition which the Veteran wishes to submit. Attach any evidence received to the Veteran's file. 2. Obtain an addendum medical opinion from the examiner who provided the August 2020 medical opinion, if available, and if not from another qualified clinician. Neither a new examination of the Veteran nor any additional tests are requested unless indicated by the examiner providing the addendum opinion. The VA examiner is asked to provide the following: (a.) State whether the Veteran's G-6PD condition is a congenital or developmental defect or disease and whether this condition pre-existed his entry into service. (b.) State whether the record contains evidence which verifies the Veteran's assertion that related to his in-service blood transfusions he was given blood or a different or incompatible blood type. (c.) Provide a medical opinion regarding: 1. whether it is at least as likely as not (50 percent probability or higher) the Veteran's G-6PD condition had its onset in service or is related to his military service, and 2. whether it is at least as likely as not (50 percent probability or higher) that the Veteran's G-6PD condition was aggravated beyond it normal progression or that a disability due to disease or injury that was incurred in service is superimposed on the congenital defect, including as to each (i) the impact of his taking malaria pills and (ii) the impact of whether or if he was given blood of a different or incompatible type during his in-service blood transfusions. The examiner is asked to fully explain the reasons behind any opinions expressed and conclusions reached. 3. After receipt of the above requested evidence and opinions, re-adjudicate the Veteran's claim. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bannach, Keith 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.