Citation Nr: 23052283 Decision Date: 09/21/23 Archive Date: 09/21/23 DOCKET NO. 18-48 875 DATE: September 21, 2023 ORDER Entitlement to an increased evaluation of 70 percent, but no higher, for service-connected posttraumatic stress disorder (PTSD), effective November 8, 2016, is granted. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is granted. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's PTSD more closely approximated occupational and social impairment with deficiencies in most areas, effective November 8, 2016, but does not result in total occupational and social impairment. 2. The evidence of record demonstrates that the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an increased 70 percent disability rating for service-connected PTSD from November 8, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1963 to May 1966, to include service in Vietnam. His decorations include an Armed Forces Expeditionary Medal, Navy-Marine Corps Parachute Insignia, and Parachutist Insignia (RVN). These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge during a March 2023 hearing. A copy of the transcript has been associated with the file. These matters were previously before the Board in September 2020. While on remand, the RO increased the Veteran's PTSD rating from 50 percent to 70 percent, effective February 12, 2021. However, as 70 percent is not the highest rating available for PTSD, the claim is still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In addition, on remand, the RO granted service connection for bladder cancer. As this constitutes a full grant of the benefit sought on appeal, that issue is no longer before the Board. As a preliminary matter, the Veteran essentially testified that he was seeking an earlier effective date for the award of the 70 percent rating for his PTSD, which he argues should be effective November 2016, the date he filed his increased rating claim or October 2017 the date of his VA examination that showed increased symptoms. The Board observes that the Veteran filed his claim in November 2016 and his appeal originates from an April 2017 rating decision that continued his 50 percent evaluation. The issue before the Board is essentially an increased rating claim for PTSD and not an earlier effective date. Thus, the issue is properly framed as entitlement to an increased rating for PTSD prior to February 12, 2021, not an earlier effective date. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902. Increased Ratings Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Separate ratings may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a disability rating higher than 50 percent prior to February 12, 2021 and 70 percent thereafter for service-connected PTSD. As noted above, the Veteran contends that his 70 percent evaluation for PTSD should have an earlier effective date than February 12, 2021. Specifically, the Veteran contends that the effective date of his 70 percent evaluation should be November 8, 2016, the date of his increased rating claim. See Hearing Transcript, Page 17. By way of background, the Veteran's PTSD has been rated 30 percent disabling effective December 30, 2003; 50 percent disabling effective January 23, 2007; and 70 percent disabling effective February 12, 2021. The Veteran's PTSD is rated under Diagnostic Code 9411. Psychiatric disorders, however diagnosed, are rated under the General Rating Formula for Mental Disorders. A 70 percent rating is manifested by 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), or an inability to establish and maintain effective relationships. Id. The maximum rating available of 100 percent is assigned when 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 (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. Under the General Formula for Mental Disorders, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). When evaluating a mental disorder, 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. See 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). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Turning to the evidence of record, a July 2017 VA treatment record noted the Veteran denied any hopeless feelings about the present or future, or any suicidal thoughts. The Veteran was afforded a VA examination to assess the current severity of his PTSD in October 2017. The examiner determined the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. The Veteran reported he lived alone for the past 15 years in Alaska and occasionally goes to San Diego, CA for a month in the winter. He reported he occasionally gets together with a few neighbors throughout the year and noted a cordial relationship with several family members and three sisters. No mental health treatment was noted in the past 10 years. He reported his typical day includes hiking, fishing, splitting wood, reading, and gardening during the summer months. He endorsed symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment (only 4-5 hours a night), difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner determined he was competent to handle his own financial affairs and described him as pleasant and cooperative throughout the interview. The examiner reported that the Veteran's PTSD symptoms, including sleep disturbances, feelings of detachment from others, persistent inability to experience positive emotions, dissociative reactions, and recurrent distressing dreams would cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran underwent a psychological evaluation by a private provider in July 2018. He reported severe insomnia, fatigue, hypervigilance, intrusive thoughts daily, irritability, anxiety, anger, isolation, withdrawal, paranoia, avoidant behavior, and recurrent nightmares and flashbacks. He noted he had not worked in several years and admitted to conflicts with coworkers and supervisors. He indicated he lives in an isolated area and infrequently will go to San Diego, CA and Anchorage, AK for supplies, but otherwise stays isolated. Current psychological symptoms included revivification experiences including recurrent nightmares, daily flashbacks, some dissociative episodes, isolative and avoidant behavior, hypervigilance in public, anxiety in crowds, significant sleep impairment (four to five hours per night), fatigue, feelings of worthlessness, loss of interest, social isolation, irritability, chronic tension, frustration, passive suicidal ideations with no history of intent or plan, diminished memory and concentration, hyper-startle reaction, panic-like symptoms, and feelings of emptiness, boredom, and apathy. Ultimately, the examiner opined that the Veteran's PTSD symptoms approximated a 70 percent rating at least for the past 5 years. For rationale, the psychologist noted his treatment records documented ongoing symptoms of recurring nightmares and sleep impairment. In addition, his 2017 VA examination identified significant symptoms to include hypervigilance, exaggerated startle response, sleep disturbance, depressed mood, anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances. At that time, the Veteran reported experiencing intrusive memories several times a week and experiencing pervasive guilt, emotional distancing, and poor concentration. The psychologist noted the Veteran is highly reclusive to the point where he lives alone in an isolated area with no meaningful relationships; to include never being married, no close interpersonal relationships, and no children. A May 2019 VA treatment record noted chronic insomnia related to his PTSD. He reported getting only 3 hours of sleep the night prior, despite the use of his prescribed sleep aid. During his February 2021 VA mental disability examination, the examiner characterized the Veteran's PTSD as being productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported he lived alone, was single, with no children. He noted some friends and had occasional contact with his sisters who live out of state. The Veteran described fleeting, passive suicidal ideations occasionally but denied any current suicidal or homicidal ideations, psychosis, or delusions. Current symptoms included depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near continuous panic or depression affecting the ability to function independently; chronic sleep impairment; mild memory loss; impairment of short and long term memory; flattened affect; circumstantial, circumlocutory, or stereotyped speech; speech intermittently illogical, obscure, or irrelevant; impaired abstract thinking; 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 work like setting; obsessional rituals which interfere with routine activities; and impaired impulse control. Upon mental status examination, the Veteran was described as alert and fully oriented, well-groomed, and clean. His thought processes were linear and goal-directed, and he was polite and friendly. The examiner reported his PTSD symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. During his March 2023 Board hearing, he clarified that the 70 percent rating assigned was likely correct, but an earlier effective date than February 2021 was warranted for the increased rating. Specifically, his representative argued his 70 percent disability rating should go back to the date of his increased rating claim, November 8, 2016, or at least his October 2017 examination that showed worsening symptoms. See Hearing Transcript, Page 17. On review, the Board finds that a 70 percent rating is warranted for the entire rating period on appeal, beginning November 8, 2016. In so finding, the Board notes that the Veteran's PTSD resulted in deficiencies in most areas. Significantly, both the October 2017 and February 2021 VA examiners found that his PTSD would cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Likewise, the psychologist who performed the July 2018 psychological examination found the Veteran's symptoms were indicative of deficiencies in most areas, by VA standards. The evidence illustrates the Veteran had no significant relationships. In fact, the Veteran reported he has lived alone for the past 15 years, engaged in no long-term relationships, and never had kids. A review of the record showed that with the exception of having coffee with fellow veterans or attending gatherings with neighbors a few times a year, he has been detached from others with no significant social relationships. Accordingly, as for the effective date of the grant of a 70 percent rating, the Board will resolve reasonable doubt in the Veteran's favor that at the time he filed his increased rating claim on November 8, 2016 his PTSD also met the criteria for a 70 percent rating, warranting an effective date of November 8, 2016. Nonetheless, at no time did the Veteran demonstrate total occupational and social impairment, indicative of a 100 percent disability rating. With respect to occupational impairment, the evidence shows that the Veteran did not work during the appeal period. He testified he stopped working in the 1990s, and had attempted to trade stocks in the 1970s in Los Angeles, but could not deal with the congestion, traffic, and working around others. After switching to manual labor, he noted he left construction due to conflicts with authority figures and coworkers. Regarding social impairment, although his PTSD results in social impairment, such impairment is not considered "total." The Veteran was able to interact with others, even if infrequently, and independently maintain the activities of daily living, including having hobbies like fishing. He reported occasional gatherings with neighbors and at least some contact with family members and his sisters. He also noted he has coffee weekly with fellow veterans. Although he has lived alone, with limited contact with his family, he still has noted occasional contact with friends and family throughout the appeal period. Total occupational and social impairment generally requires symptoms severe enough to severely distort the individual's perception of reality, which is not shown by the record. Overall, the Veteran's psychiatric symptoms do not equate in severity, frequency, or duration to total occupational and social impairment, nor have the symptoms demonstrated a level of severity in symptomatology to approximate or equate to that in the symptoms listed for a 100 percent rating. Additionally, the identified PTSD symptoms of chronic sleep impairment; mild memory loss; impairment of short and long term memory; flattened affect; circumstantial, circumlocutory, or stereotyped speech; speech intermittently illogical, obscure, or irrelevant; impaired abstract thinking; 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 work like setting; obsessional rituals which interfere with routine activities; and impaired impulse control, are properly contemplated by the currently assigned 70 percent disability rating. He has been found capable of managing his own financial affairs and has consistently appeared fully oriented throughout the appeal period. On mental status examinations, he always presented as adequately dressed and groomed and as such there is no evidence of neglect in hygiene. There is also no evidence of delusions or hallucinations at any time during the pendency of the appeal. Additionally, no VA examiner has determined that the Veteran's impairment is akin to total social and occupational impairment, nor does the evidence or Veteran suggest that. In fact, the Board acknowledges during his March 2023 hearing, the Veteran's representative argued that the 70 percent rating is likely the correct evaluation, with the addition of TDIU. See Hearing Transcript, Page 22. In summary, the Board finds that a 70 percent disability rating, but not higher, is warranted for the Veteran's PTSD for the period since he filed his increased rating claim, November 8, 2016. 2. Entitlement to a TDIU The Veteran contends he is unemployable due to his service-connected disabilities. He filed a claim for TDIU in September 2017 in which he listed unemployability due to his PTSD. Legal Criteria VA will grant a total rating for compensation purposes based on unemployability when the evidence shows a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of service-connected disabilities.??38?C.F.R. §§?3.340, 3.341, 4.16.??In reaching such a determination, 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).??? The question in a?TDIU?claim is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment.??A high disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment.??See Van?Hoose?v. Brown,?4?Vet. App.?361?(1993).??In determining whether unemployability exists, consideration may be given to the?veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. See?38?C.F.R. §§?3.341, 4.16, 4.19.? Substantially gainful employment is defined as work that is more than marginal, which permits the individual to earn a?"living wage."??Faust v.?West,?13?Vet. App.?342 (2000). The Court of Appeals for Veterans Claims has held that the term?"unable to secure and follow a substantially gainful occupation"?in 38?C.F.R. §?4.16?has two components.??First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person.??Second, there is a non-economic component dealing with the individual veteran's ability to?"follow and secure"?employment.?? For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work?place stress, get along with coworkers and demonstrate reliability and productivity.??Ray v.?Wilkie,?31?Vet. App.?58, 73?(2019).? If there is only one service-connected disability, it must be rated at least 60 percent disabling to qualify for?TDIU?benefits; 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). The Board is cognizant that the Court held in Withers v. Wilkie, "where a veteran's ability to perform sedentary work is a basis for the Board's decision, the meaning of sedentary work must be determined from the particulars of the medical opinion in which it is used." Withers, 30 Vet. App. 139, 147 (2018). In other words, the Court stated that "the Board must explain this meaning . . . as well as how the concept of sedentary work factors into the veteran's overall disability picture and vocational history, and the veteran's ability to secure or follow a substantially gainful occupation." Id. In this regard, the Board notes that the Social Security Administration (SSA) defines sedentary work as work that involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. 20 C.F.R. 404.1567. Although a sedentary job is defined as one that involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Id. Jobs are sedentary if walking and standing are required occasionally, and other sedentary criteria are met. Id. The Board finds this definition persuasive. Analysis As an initial matter, the Board notes that the Veteran is service connected for PTSD, evaluated at 70 percent disabling from November 8, 2016 (earlier effective date granted herein); bladder cancer, evaluated at 20 percent disabling from November 8, 2015; left lower extremity radiculopathy associated with lumbar degenerative disc disease, evaluated at 20 percent disabling from November 8, 2016; tinnitus, evaluated at 10 percent disabling effective December 30, 2003; lumbar degenerative disc disease, evaluated at 10 percent disabling effective November 8, 2016; bilateral hearing loss, evaluated as noncompensable from December 30, 2003; and bladder cancer residual scars, evaluated as noncompensable from November 8, 2015. The Veteran's combined disability rating is 90 percent from November 8, 2016. As such, the narrow issue before the Board is whether the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. In his VA Form 21-8940 Application for Increased Compensation Based on Unemployability received in September 2017, the Veteran contended his PTSD prevents him from securing substantially gainful employment. He reported he became too disabled to work in 1993 and noted he had an altercation with his foreman. The record reflects that the Veteran completed college with a degree in economics. See VA Form 21-8940; VA treatment record, October 2008. Historically, his employment history includes trading stocks on the stock exchange, carpentry, land surveyor, and construction. With the Veteran's occupational history and educational attainment established, the Board turns to its analysis regarding entitlement to a TDIU. The Board is cognizant the Veteran has essentially contended his PTSD is the sole reason he is not able to work. However, the Board will also address his other service-connected disabilities and the effect, if any, on occupational functioning. Turning to the relevant evidence, the Veteran was provided a VA mental examination in October 2017. The examiner found his chronic PTSD resulted in occupational and social impairment with reduced reliability and productivity. He reported he last worked full time in 1975 or 1976 and had a problem with the foreman. Symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted his ability to interact with peers/supervisors/customers is considered moderately impaired. His ability to sustain concentration to perform simple routine tasks, complex tasks, and engage in multi-step problem solving is considered mildly impaired. During his psychological evaluation by a private provider in July 2018, the Veteran reported he had not worked substantially since around 1993 to 1994 and reported a hard time getting along with people and keeping jobs. He reported his occupational history included work on the Alaska pipeline in the 1970s and construction but had conflicts with his foreman. He reported significant sleep impairment and noted 4-5 hours of sleep a night. Based on the psychologists vocational and clinical expertise, she opined the Veteran's PTSD symptoms would preclude him from engaging in substantially gainful employment for at least the past 5 years. The examiner noted the Veteran reported difficulty sustaining jobs secondary to his PTSD symptoms including irritability, anger, social withdrawal, anxiety, hypervigilance, and low motivation. She noted he would often have conflicts with coworkers and supervisors. The psychologist found that the Veteran does not have effective coping mechanisms and is unable to adapt to stressful circumstances and would be unable to maintain acceptable levels of productivity and attendance, nor relate appropriately to supervisors and coworkers. The Veteran was afforded a VA back examination in May 2018. The Veteran reported chronic low back pain since Vietnam. Ultimately, the examiner determined that the Veteran's back disability would impact his ability to perform physical labor but would not impact his ability to perform all aspects of sedentary work. Likewise, during his July 2020 VA back examination, the Veteran reported a history of low back pain with left lower extremity radiculopathy. The examiner determined his back disability would impact his ability to perform physical labor such as rucking, running, walking/standing, bending/stooping, squatting, kneeling, and lifting. It would not impact his ability to perform all aspects of sedentary work, such as typing/computer work, filing, answering the phone, and greeting customers. The Veteran was provided a VA bladder examination in January 2021. A 2008 diagnosis of bladder cancer was noted. The examiner determined his diagnosis would not have an impact on his ability to work. During his February 2021 VA mental disability examination, the examiner determined his PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, circumstantial, circumlocutory or stereotyped speech, speech intermittently illogical, obscure, or irrelevant, impaired abstract thinking, 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 work like setting, obsessional rituals with interfere with routine activities, and impaired impulse control. Since his last examination in 2017, the Veteran reported he had not worked. During his March 2023 Board hearing, the Veteran testified he last worked in 1993. He reported past employment history included trading stocks on the stock exchange and construction. Hearing Transcript, Page 6. He testified he traded stocks in 1972 in Los Angeles but stopped after being triggered by things like traffic and having to interact with people. Hearing Transcript, Page 6. He testified he switched to manual labor, specifically construction, in Alaska but stopped working due to issues with his foreman, authority figures, and co-workers. He reported irritability from nightmares and flashbacks which impacted his ability to sleep and focus during work. Hearing Transcript, Page 7. In considering the question of the Veteran's capability of securing and following substantially gainful employment, the evidence indicates he would have difficulty maintaining employment due to the physical limitations imposed by his service-connected disabilities such as his chronic lower back pain and associated left lower extremity radiculopathy. The Board highlights the Veteran's limited employment history. In this regard, the Veteran primarily worked in physically demanding jobs that are no longer feasible due to his back and lower extremity disabilities. In addition, his PTSD symptoms including chronic sleep impairment, limited focus and concentration, irritability, and disturbances of motivation and mood would be of such nature and severity as to preclude substantially gainful employment. In fact, both the 2017 and 2021 VA examiners found the Veteran would experience difficulty in adapting to stressful circumstances, including work or a worklike setting. Furthermore, the Veteran appears to have no experience or transferrable skills for sedentary type employment, such as clerical work. The record does not indicate that the Veteran has the experience or training in other fields and could easily transition effectively into a sedentary work environment. Thus, the Board will resolve reasonable doubt in the Veteran's favor and award entitlement to TDIU. Entitlement to a TDIU is a legal determination, not a medical one. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Medical examiners may provide evidence regarding functional and occupational impairment, but the Board must decide whether a veteran may "secure and follow a substantially gainful occupation" based on all evidence of record. See Delrio v. Wilkie, 32 Vet. App. 232, 243 (2019). Based on the specific evidence submitted in this Veteran's case, the Board will resolve reasonable doubt in his favor and find that his service-connected disabilities, in the aggregate, likely precluded him from securing and following substantially gainful employment. The collective impact of the Veteran's service-connected disabilities on his ability to work is the most probative evidence for a grant of TDIU. Accordingly, TDIU is therefore warranted. To be as favorable as possible to the Veteran, the Board will allow the agency of original jurisdiction to assign the effective date for the grant of TDIU in the first instance. Urban v. Principi, 18 Vet. App. 143, 145 (2004) (per curium order) ("To the extent that [the appellant] is arguing that the Board must assign, sua sponte, an effective date once it awards a rating of TDIU on appeal from an AOJ decision, such an argument is unavailing unless a notice of disagreement is then of record as to the downstream issue of an effective date for the assignment of that rating"). Colleen M. Glaser-Allen Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Krista Johnson, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.