Citation Nr: A25035500 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 231218-404953 DATE: April 17, 2025 ORDER Entitlement to a rating greater than 70 percent for an acquired psychiatric disorder to include posttraumatic stress disorder with generalized anxiety disorder, alcohol use disorder, and sleep disturbances is denied. Entitlement to total disability based on individual unemployability is denied. Entitlement to service connection for a left-hand strain (claimed as joint pain in fingers) is granted. Entitlement to service connection for a right-hand strain (claimed as joint pain in fingers) is granted. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's symptoms did not more closely approximate total occupational and social impairment. 2. The Veteran was not unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 3. Resolving reasonable doubt in the Veteran's favor, left hand strain is at least as likely as not related to constantly holding equipment. 4. Resolving reasonable doubt in the Veteran's favor, right hand strain is at least as likely as not related to constantly holding equipment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent for an acquired psychiatric disorder have not 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 entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16(a). 3. The criteria for service connection for left hand strain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for right hand strain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 2004 to December 2013 to include over four years of service in both Afghanistan and Iraq. The Veteran's DD-214 includes decorations to include the Army Commendation Medal, Army Achievement Medal, the Afghanistan Campaign Medal with Two Campaign Stars, and numerous service ribbons. The Veteran was also noted as serving in a designated imminent danger pay area. In April 2015, the Veteran filed her initial claim for posttraumatic stress disorder (PTSD). In September 2015, the Department of Veterans Affairs (VA) Regional Office (RO) issued a Rating Decision granting service connection for PTSD and awarding a 50 percent rating effective April 30, 2015. In December 2015, the Veteran filed a Notice of Disagreement (NOD) indicating that she was seeking an increased initial rating. In August 2016, the Veteran filed a claim for adjustment disorder, anxiety, and attention deficit disorder. In December 2017, the Veteran filed a new claim for anxiety as secondary to her service-connected PTSD. In April 2018, the Veteran filed a new claim for PTSD. A December 2019 RO decision increased the Veteran's PTSD rating to 70 percent and maintained the April 30, 2015, effective date. The Veteran did not file a timely appeal and this decision became final. In November 2021, the Veteran filed a new claim for PTSD. A February 2022, RO rating decision continued the 70 percent PTSD rating. In May 2022, the Veteran filed a supplemental claim seeking an increased rating for her PTSD and claiming total disability based on individual unemployability (TDIU). The Veteran also submitted VA Form 21-8940 Application for Increased Compensation Based on Unemployability along with this claim. A June 2022 rating decision continued the Veteran's 70 percent PTSD rating. No decision on TDIU was made. In November 2022, an RO rating decision continued the Veteran's 70 percent PTSD rating while deferring a decision on TDIU until additional development was completed. In February 2023, with additional development completed, the RO denied the Veteran's claim for TDIU noting that the Veteran was capable of gainful employment. This decision did note that the Veteran met the schedular criteria for a TDIU consideration. In May 2023, the Veteran filed a claim for joint pain in fingers and sleep disturbances plus alcohol dependance. In July 2023, an RO decision denied an increased rating for PTSD finding that there had been no change in severity. That rating decision deferred a finding on joint pain in the fingers pending a VA medical examination and opinion. In an October 2023 rating decision, the RO denied service connection for both a left- and right-hand strain. The RO found that the VA examination of record provided a negative opinion for toxic exposure risk assessment (TERA). An additional October 2023, rating decision denied an increased rating for the Veteran's PTSD and continued the 70 percent rating. In December 2023, the Veteran appealed February 2023, July 2023, and both October 2023 rating decisions to the Board of Veterans' Appeals (Board) via a VA Form 10182 (Decision Review Request: Board Appeal (Notice of Disagreement)). The Veteran requested the Direct Review docket. As an appeal in which the appellant requested, on the Notice of Disagreement, direct review by the Board without submission of additional evidence and without a Board hearing, the Board's decision is based on a review of the evidence of record at the time of the respective decisions on the issues on appeal. 38 C.F.R. § 20.301. Evidence has been submitted during a window of time when the Board may not consider it in reaching this decision. This evidence includes, but is not limited to, additional medical records. If the Veteran wishes for this evidence to be considered, he may do so by filing a supplemental claim. Instructions for filing a supplemental claim are included with this decision. The Veteran has filed multiple claims for various psychiatric disorders to include anxiety, PTSD, sleep disturbances and alcohol use disorder. The Board has recharacterized these claims as a claim for an increased rating for her acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record). Due to restrictions on compensating a Veteran for the same symptoms under multiple diagnoses, the Board notes that all of the Veteran's psychological diagnoses are rated under the general rating formula. Entitlement to a rating greater than 70 percent for an acquired psychiatric disorder. In an April 2024 Informal Hearing Presentation (IHP), the Veteran's representative argued that her record warrants a rating in excess of 70 percent for her PTSD. The IHP specifically points to the Veteran's habit of drinking two bottles of wine a day, that she is unable to cook and clean and that she relied on her mother and friend to do these things for her. The IHP continued by noting that the Veteran moved away from her friends and family to live in isolation and that her own child no longer lived with her. The Veteran was also noted as being in the midst of divorce and that despite being a Chaplain's assistant in the military she had lost her religion. Despite these contentions, the Board finds that a 100 percent rating is not warranted as discussed below. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's acquired psychiatric disorder was rated under 38 C.F.R. § 4.130, DC 9411; however, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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. A total schedular rating of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In August 2015, the Veteran underwent a VA examination for an acquired psychiatric disorder. The examiner diagnosed the Veteran with PTSD. There were no additional mental disorders diagnosed. Overall, the examiner found that the Veteran was suffering from occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported a history of two prior marriages both ending in divorce. She lived alone. The Veteran had taken some college courses and was currently employed as a property specialist. The Veteran did not get attached to people as she had developed a fear of losing people. The Veteran reported difficulty falling asleep, frequent waking, night sweats, irritability, socially isolated, hypervigilance, being easily startled, short term memory problems, poor focus and concentration, and poor appetite. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss such as forgetting names direction or recent events, 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, inability to establish and maintain effective relationships. The examiner noted that the Veteran did not pose a danger to herself or others. In her December 2015, NOD the Veteran said she was occupationally and socially impaired and unable to adjust to her civilian surroundings. She described herself as frequently depressed and self-isolated. She further indicated that she suffered from unprovoked irritation and violent impulses. In May 2018, the Veteran underwent a new VA examination. The examiner diagnosed the Veteran with PTSD and generalized anxiety disorder. The examiner noted that it was not possible to differentiate which symptoms belong to which diagnosis. The Veteran described her educational history as having over 90 college credits and that she was enrolled at the Art Institute of Atlanta and that she had also attended the Atlanta School of Massage for a specialty in personal training. She finished the massage school but did not go back to take the test. The Veteran reported that she did not do well with driving and traffic. She was currently taking Sertraline 50 mg. once per day. The Veteran denied any previous hospitalizations or past suicidal ideations. The Veteran's symptoms included depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss such as forgetting names, direction, or recent events, flattened affect, 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. The examiner described the Veteran as alert and oriented to all spheres with cognition and judgment that appeared to be intact. The Veteran did not pose a threat to herself or to others. In September 2018, the Veteran was seen for mental health treatment. She described maintaining employment as difficult due to her symptoms. The Veteran had no interest in maintaining relationships. She was unemployed with a history of work at a call center, a doctor's office, a moving specialist, an executive assistant, and an assistant manager at a DSW all over the past two years. The Veteran said she purposely had no friends. The Veteran denied both suicidal and homicidal ideations. The Veteran was described as alert and oriented, having normal speech, her mood was anxious, affect was congruent with mood. The Veteran denied perceptual disturbances. Her insight and judgment were good. In September 2021, she was again seen for mental health treatment. The Veteran was taking Klonopin, melatonin, Paxil, and prazosin. She complained of not sleeping well and that her appetite was not great. She did report that her moods had been stable since her previous visit. She reported waking up at night due to nightmares and hearing noises that her husband did not hear. The Veteran denied both homicidal and suicidal ideations. In December 2021, she was again seen and described as alert and attentive. Her speech was normal with a coherent thought process. The report says the Veteran had good insight and judgment within normal limits. In December 2021, the Veteran's father submitted a lay statement about her acquired psychiatric disorder. He reported that the Veteran was unable to leave home as she constantly hears explosive sounds. The Veteran was said to be unable to maintain any social or romantic relationships. He described her as always anxious and overly aggressive. He believed that her condition had worsened. In January 2022, the Veteran was seen for a new VA examination. The Veteran reported always being on guard and anticipating that something bad would happen. The Veteran had last worked in 2018. She did indicate some suicidal ideations in the past but she denied any current suicidal or homicidal ideations. The Veteran had started to drink to help her sleep and deal with anxiety, but new medication had helped her to stop. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once per week, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss such as forgetting names directions or recent event, flattened affect, circumstantial, circumlocutory or stereotyped speech, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstance including work or a work like setting, inability to establish and maintain effective relationships, and suicidal ideation. The examiner described the Veteran as alert, oriented to person place and time, casually dressed and groomed. The Veteran was reported to be guarded with a constricted affect. The examiner noted that the Veteran's responses to her marital history and current living situation were inconsistent and unclear. Additional PTSD symptoms included anger, irritability, trouble concentrating, and flashbacks. The Veteran was found to be capable of managing her own financial affairs. Overall, the examiner found the Veteran was suffering from social and occupational impairment with deficiencies in most areas such as work, school, family relations, judgment, and thinking or mood. In March 2022, the Veteran was treated for her mental health and indicated suffering no suicidal thoughts over the past month. In May 2022, a new VA examination was completed. The Veteran indicated that she isolated herself socially and that she struggled to maintain various types of relationships especially romantic ones. Her symptoms included depressed mood, anxiety, suspiciousness, flattened affect, 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. There were no other symptoms present. The examiner reported the Veteran presented with a flat affect and was dressed appropriately. The Veteran was capable of managing her own financial affairs. There was not an elevated acute risk of suicide. Overall, the examiner found the Veteran was suffering from social and occupational impairment with deficiencies in most areas such as work, school, family relations, judgment, and thinking or mood. In December 2022, the Veteran underwent a new VA examination. The Veteran was diagnosed with PTSD. The Veteran was currently going through a divorce after being separated for eight months. The Veteran was not currently employed and stated that she last worked in a call center for six years but stopped working due to "it not working". It is unclear exactly what this means. The Veteran reported anxiety when attempting to communicate with others. The Veteran endorsed feeling of hopelessness, worthlessness, difficulty with motivation, and feelings of sadness. The Veteran endorsed feeling anxious, nervous, restless, irritability, and anger. There was a contradictory finding in the examination as it noted that the Veteran was able to dress, bathe, groom, cook, and clean but shortly thereafter stated that the Veteran does not do any cooking or cleaning. The Veteran reported symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstance including work or a work like setting. The examiner reported the Veteran was oriented properly, her attitude was cooperative and engaged, she was alert with unimpaired concentration, normal speech, judgment was intact, insight was fair, thoughts were coherent and linear, and memory was fair. There were no signs of perceptual disturbances observed. The Veteran denied current suicidal and homicidal ideations. There was no evidence of psychiatric hospitalizations, hallucinations, or delusions. The Veteran was attempting to go through VA counseling. Overall, the examiner found the Veteran was suffering from social and occupational impairment with deficiencies in most areas such as work, school, family relations, judgment, and thinking or mood. In May 2023, the most recent VA examination for PTSD was completed. The Veteran was diagnosed with PTSD, generalized anxiety disorder, and alcohol use disorder. The examiner found that it was not possible to differentiate which symptoms were attributable to which diagnosis. The Veteran reported that the issues in her marriage were related to her mood symptoms and behaviors. The Veteran reported mainly staying at home in her room and not going out. The Veteran reported that there had been no changes or improvement in her symptoms since her last exam. The Veteran also continued to experience depression, anxiety, panic attacks, excessive worrying, overthinking and assuming the worst. The Veteran was hypervigilant, suspicious, and avoidant. The Veteran also had difficulties sleeping at times due to her anxiety. The Veteran had been in an outpatient program since February and attends sessions weekly and she now goes to therapy twice a month. The Veteran reported that she signed up to enter an inpatient PTSD program within the next few months. She was prescribed Mirtazapine 30mg that she had taken but found to be ineffective. The Veteran was also prescribed medication to treat her alcohol craving including Naltrexone 50mg and Gabapentin. The Veteran indicated she drank between 1.5-2 bottles of wine per day. The examiner stated that the Veteran's alcohol use was considered to be a maladaptive means of coping with her chronic PTSD and anxiety symptoms. Her symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss such as forgetting names, directions or recent events, flattened affect, circumstantial, circumlocutory or stereotyped speech, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstance including work or a work like setting, inability to establish and maintain effective relationships, and neglect of personal appearance and hygiene. The examiner reported the Veteran was alert and oriented to person, place, time, and situation. Memory, concentration, and attention were impaired as she was easily distracted, and questions had to be repeated. The Veteran answered all questions but did not maintain consistent eye contact. Her speech was rapid and circumstantial. Veteran presented as depressed, distressed, and anxious. She was very restless during the entire exam. Veteran did not report or exhibit any symptoms of thought disorder, but she was distracted. Veteran denied any suicidal ideation, intent or plan and did not present as a risk for self-harm. Overall, the examiner found the Veteran was suffering from social and occupational impairment with deficiencies in most areas such as work, school, family relations, judgment, and thinking or mood. The Board finds that the totality of the evidence does not support a rating of 100 percent for the Veteran's acquired psychiatric disorder. None of the VA examiners have found the Veteran to be suffering from total occupational and social impairment. The Veteran has had one instance of suicidal ideation but has consistently been found to not be a threat to herself or others. The Veteran has not been found to be suffering from delusions or hallucinations. There have been instances of the Veteran waking up and hearing noises in the house that her then husband could not hear, but there is no indication that these are auditory hallucinations. Each VA examiner found the Veteran to be oriented to time and place and not suffering from any disorientation. While the Veteran had some memory issues these were not so severe to result in forgetting names of close relative or her own name. The vast majority of the Veteran's symptoms and complaints fit more squarely into the criteria for a 70 percent rating. This includes some deficiencies in judgment, some neglect of personal appearance, and difficulty in adapting to stressful circumstances. Therefore, an increased rating of 100 percent is not warranted, and the claim is denied. In reaching this conclusion, the Board has considered and applied the benefit-of-the-doubt rule. "When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant." 38 U.S.C. § 5107(b). "Evidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other." Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021); see also Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). In this case, the evidence persuasively favors a finding that the Veteran's symptoms more closely represent occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Thus, the benefit-of-the-doubt rule does not change the outcome on this issue. Entitlement to total disability based on individual unemployability. In her May 2022 VA Form 21-8940, the Veteran noted that she was unable to work as a result of her PTSD. TDIU may be assigned 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. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. Entitlement to a total rating must be based solely on the impact of a veteran's service-connected disabilities on their ability to secure and follow substantially gainful employment. See 38 C.F.R. § 4.16(a). 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). Individual unemployability must be determined without regard to any nonservice-connected disabilities or a veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough to show unemployability. A high rating in and of itself is recognition that the impairment makes it difficult to secure or follow employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose, 4 Vet. App. at 363. Thus, the Board must evaluate whether there are circumstances in a veteran's case, apart from any nonservice-connected conditions and advancing age, which would justify a TDIU rating. 38 C.F.R. § § 3.341(a), 4.16, 4.19. Van Hoose, 4 Vet. App. at 363. A veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). In her May 2022 application for TDIU, the Veteran reported that she last worked full-time January 1, 2017, but that her disability first affected her full-time work on May 1, 2015. She stated that her PTSD was the only disability preventing her from following a substantially gainful occupation. The Veteran's education noted two years of high school and two years of college. The Veteran completed personal training and sports nutrition training post-service. In May 2022, a rehabilitation needs inventory was completed. The Veteran indicated that she was seeking to obtain education needed to participate in a job that worked for her. She was seeking a career in alternative medicine or herbalism. The Veteran reported that her disabilities impacted her ability to relate to her managers and co-workers. In June 2022, the Veteran was granted vocational rehabilitation and education. In August 2022, there is an academic report which stated the Veteran anticipated finishing a bachelor's degree of Science in Holistic Nutrition in April 2025. In October 2022, vocational rehabilitation provided a feasibility determination for the Veteran's goals. It stated that that the Veteran's goal of work in the area of Nutrition was feasible. The field did not appear to aggravate her stated disabilities and the Veteran's physical and mental conditions appear to permit exploration of this occupation. The examiner stated that the Veteran's service-connected disabilities appear not to be aggravated by this type of profession as the duties and activities of this occupation are primarily sedentary. Sedentary employment is the common meaning in society of non-physical, white collar, office-type work. In December 2022, the VA examiner focused on the Veteran's acquired psychiatric disorder and discussed her ability to function in an occupational environment. The examiner reported that the Veteran exhibited a number of symptoms of PTSD that would moderately impair her ability to work in both sedentary and more active work environments if she were otherwise physically able to do so. Irritability, social withdrawal and alienation, poor coping strategies and her inability to tolerate being around small groups of people would interfere with her ability to interact and relate effectively with others. She may perform better in tasks that require interaction (via phone or in person) with no or few people. Difficulty with concentration, problems with focus, the presence of intrusive thoughts, anxiety, and hyper-vigilance would interfere with her ability to effectively manage workplace tasks and demands in a consistent and productive manner. Poor sleep and associated daytime fatigue, avoidance, low mood and motivation, and difficulty functioning in stressful situations would reduce workplace reliability and efficiency. Thus, the examiner found it would be difficult for the Veteran to secure or to maintain occupational engagement in occupational environments and settings that are conducted in a high stress environment. She would be most likely to succeed in an occupational environment that offers a low stress environment, with continuous routine tasks. A home environment or one that required few interactions with others would further increase the chance of her success. The Board finds that the totality of the evidence does not support a finding of total disability based on individual unemployability. The October 2022 vocational rehabilitation feasibility determination as well as the December 2022 VA examiner both argued that the Veteran would be able to obtain substantially gainful employment. The October 2022 report indicated that the Veteran would be able to obtain work in her desired field of nutrition as this type of work did not appear to aggravate her service-connected disabilities. The December 2022 examiner also noted that the Veteran could succeed in a low stress environment and that a home environment or one with few interactions would increase her chances of success. Based on this, the Board finds that the Veteran's service-connected disabilities do not prevent the Veteran from obtaining and maintaining substantially gainful employment, and therefore the claim for TDIU is denied. In reaching this conclusion, the Board has considered and applied the benefit-of-the-doubt rule. "When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant." 38 U.S.C. § 5107(b). "Evidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other." Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021); see also Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). In this case, the evidence persuasively favors a finding that the Veteran's service-connected disabilities do not result in an inability to obtain and maintain substantially gainful employment. Thus, the benefit-of-the-doubt rule does not change the outcome on this issue. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Entitlement to service connection for a left- and right-hand strain (claimed as joint pain in fingers). The Veteran is seeking service connection for the left- and right-hand strain. At her September 2023 VA examination, the Veteran said that her injured hands were caused by constantly holding equipment which weighed in excess of 50 pounds. This overuse made her hands stiff and painful. At the Veteran's September 2023 VA examination, she was diagnosed with a bilateral hand strain. Therefore, the first element of service connection has been met. As mentioned earlier, the Veteran had a distinguished service career including over four years of foreign service. At the same September 2023 examination, the Veteran contended that her bilateral hand strain was the result of holding and working with equipment in excess of 50 pounds. The Board finds this to be a plausible explanation for any associated hand pain and therefore will provide the benefit of the doubt to the Veteran and find that the second element of service connection has been met. Accordingly, the only issue before the Board is if there is a causal relationship between the Veteran's bilateral hand strain and the in-service work. In October 2004, a service treatment record (STR) showed that the Veteran denied any pain within the hand. Otherwise, the STRs are blank for any complaints related to bilateral hand pain. The Veteran's May 2023 initial claim indicated she was filing for joint pain in her fingers. No specifics were provided as to the cause or to which fingers. In August 2023, the Veteran was treated for pain in her finger though again no specifics were provided in the medical record. In September 2023, the Veteran underwent a hand and finger VA examination. The examiner diagnosed the Veteran with a bilateral hand strain. The date of onset was noted as 2006-2007. The Veteran stated that she injured her hands by constantly holding equipment weighing in excess of 50 pounds during service. She stated that her hands became painful and stiff as a result. The Veteran had limited range of motion (ROM) and constant hand pain. ROM was abnormal and resulted in pain on testing. Pain was also noted on passive ROM. The Veteran treated her hands with BioFreeze and Aleve. There were no flare-ups. The Veteran suffered functional loss in her hands due to constant pain, hand swelling and marked limited ROM in her finger joints. Due to these problems, she was unable to open jars, doorknobs, grip a steering wheel, or hold eating utensils. She could not hold onto her two girls ages three and one. The examiner noted the Veteran was wearing braces on both hands. When asked for an opinion, the only opinion provided was that the Veteran's bilateral hand strain was not related to TERA. However, the Veteran did not make such a claim. The examiner failed to discuss the issues raised by the Veteran regarding the heavy equipment and the pain and stiffness in service. The Board finds that the failure of the September 2023 medical examiner to provide a direct service connection opinion to a duty-to-assist error. However, rather than remand this claim for further development, the Board will grant the benefit of the doubt to the Veteran and find that her explanation for her bilateral hand complaints is accurate. The September 2023 examiner noted that her condition began in 2006-2007 which correlates with the Veteran's time in service and there is no further indication of any hand or finger injuries following the Veteran's time in service that would justify a bilateral hand strain. Given the Veteran's decorated military service the Board has no reason to doubt her claims and therefore, providing all benefit of the doubt to the Veteran, finds that the third element of service connection has been met. Therefore, the claim for service connection for the right and left hand strains is granted. RAY BARTO SLABBEKORN, JR. Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Andrew Ledman II 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.