POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The veteran, who served from April 1979 to April 1985 and June 1987 to May 1989, appeals the denial of service connection for erectile dysfunction and the denial of an earlier effective date for PTSD. The veteran also sought an increased rating for PTSD and service connection for several secondary conditions. The Board granted service connection for PTSD and increased the evaluation to 100 percent, finding that the veteran's symptoms, including suicidal ideation, social isolation, and intermittent inability to perform basic hygiene, approximated total occupational and social impairment. The Board also granted service connection for hypertension, diabetes mellitus type II, stroke, visual field deficit, dysarthria, dysphagia, and left-sided weakness, all as secondary to PTSD and/or stroke, based on a private medical opinion that found a nexus to service-connected conditions and resolved reasonable doubt in the veteran's favor. The claim for an earlier effective date for PTSD was denied as the veteran's initial claim was filed in May 2018, and no earlier intent to file was established. The claim for erectile dysfunction was denied due to a lack of evidence linking it to service. The Board also granted entitlement to Special Monthly Compensation (SMC) based on the need for regular aid and attendance, citing evidence of the veteran's inability to manage daily activities, prepare meals, travel independently, and maintain personal hygiene, as well as his caregiver's statement. The veteran's service treatment records were negative for most claimed conditions, but the Board relied on a private medical opinion and the benefit of the doubt doctrine for the granted secondary conditions and the increased PTSD rating.

Rationale

Veteran's PTSD symptoms approximated total occupational and social impairment.; Evidence suggested persistent danger of hurting self and intermittent inability to perform personal hygiene.; Resolving reasonable doubt in favor of the veteran, a 100 percent evaluation was warranted.

Full Decision Text

Citation Nr: A25072783
Decision Date: 08/28/25	Archive Date: 08/28/25

DOCKET NO. 210802-175770
DATE: August 28, 2025

ORDER

Entitlement to a 100 percent evaluation for posttraumatic stress disorder (PTSD) is granted.

Entitlement to an effective date earlier than May 4, 2018, for the grant of service connection for PTSD is denied.

Entitlement to service connection for hypertension, as secondary to service-connected PTSD, is granted.

Entitlement to service connection for diabetes mellitus type II, as secondary to service-connected PTSD, is granted.

Entitlement to service connection for a cerebrovascular accident (stroke), as secondary to service-connected PTSD, hypertension, and diabetes mellitus, is granted.

Entitlement to service connection for bilateral visual field deficit with left temporal hemianopsia, as secondary to service-connected stroke, is granted.

Entitlement to service connection for dysarthria, as secondary to service-connected stroke, is granted.

Entitlement to service connection for dysphagia, as secondary to service-connected stroke, is granted.

Entitlement to service connection for left-sided weakness, as secondary to service-connected stroke, is granted.

Entitlement to service connection for erectile dysfunction is denied.

Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance is granted.

FINDINGS OF FACT

1.  The Veteran's PTSD more nearly approximates total occupational and social impairment.

2.  The AOJ denied a claim for service connection for depression in a final September 2010 rating decision.  Thereafter, the Veteran first filed a claim for service connection for PTSD on May 4, 2018.

3.  The Veteran's hypertension is related to his service-connected PTSD.

4.  The Veteran's diabetes mellitus type II is related to his service-connected PTSD.

5.  The Veteran's stroke is related to his service-connected PTSD, hypertension, and diabetes mellitus.

6.  The Veteran's bilateral visual field deficit with left temporal hemianopsia is related to his service-connected stroke.

7.  The Veteran's dysarthria is related to his service-connected stroke.

8.  The Veteran's dysphagia is related to his service-connected stroke.

9. The Veteran's left sided weakness is related to his service-connected stroke.

10.  The Veteran has not been shown to have erectile dysfunction that manifested in service or that is otherwise related to his military service.

11.  The Veteran's service-connected disabilities require the regular aid and attendance of another person.

CONCLUSIONS OF LAW

1.  The criteria for a 100 percent evaluation PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411.

2.  The criteria for an effective date earlier than May 4, 2018, for the grant of service connection for PTSD have not been met.  38 U.S.C. §§ 5110; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.160, 3.400.

3.  Hypertension is proximately due to or the result of service-connected PTSD.  38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4.  Diabetes mellitus type II is proximately due to or the result of service-connected PTSD.  38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5.  A cerebrovascular accident is proximately due to or the result of service-connected PTSD, hypertension, and diabetes mellitus. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

6.  A bilateral visual field deficit with left temporal hemianopsia is proximately due to or the result of a service-connected stroke. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

7.  Dysarthria is proximately due to or the result of a service-connected stroke.  38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

8.  Dysphagia is proximately due to or the result of a service-connected stroke.  38 U.S.C.
, 3.310.

6.  A bilateral visual field deficit with left temporal hemianopsia is proximately due to or the result of a service-connected stroke. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

7.  Dysarthria is proximately due to or the result of a service-connected stroke.  38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

8.  Dysphagia is proximately due to or the result of a service-connected stroke.  38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

9.  Left-sided weakness is proximately due to or the result of a service-connected stroke.  38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310.

10.  Erectile dysfunction was not incurred in active service.  38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

11.  The criteria for entitlement to SMC based on the need for aid and attendance of another person have been met. 38 U.S.C. §§ 1114; 38 C.F.R. §§ 3.102, 3.350, 3.352.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 1979 to April 1985 and from June 1987 to May 1989.

The Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), following a July 2019 rating decision.  In July 2020, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal.  The Veteran was notified of the HLR decision in August 2020.

The Veteran submitted a VA Form 10182 in August 2021 and selected the evidence submission docket.  Therefore, the Board may only consider the evidence of record at the time of the July 2019 AOJ decision on appeal, which subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182.  38 C.F.R. § 20.303.  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, he may file a supplemental claim (VA Form 20-0995) and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a supplemental claim are included with this decision.   

Law and Analysis

Neither the Veteran nor his representative has raised any pre-decisional issues with the duty to notify or duty to assist with regard to the issues decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

Service Connection

Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service.  38 U.S.C. §§ 1110, 1131.  That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease.  If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity.  38 C.F.R. §
, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

Service Connection

Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service.  38 U.S.C. §§ 1110, 1131.  That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease.  If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity.  38 C.F.R. § 3.303(b).  Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.310 (a); Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding that, under the causation standard of 38 U.S.C. § 1110, secondary service connection is warranted where a nonservice-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability).  The Federal Circuit has held that 38 C.F.R. § 3.310(b) is inconsistent with 38 U.S.C. § 1110.  Id. 

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other).

Hypertension

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is entitled to service connection for hypertension.

The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of hypertension, and his blood pressure readings were normal during service.  He was also not diagnosed with hypertension to a compensable degree within one year of active service.

Nevertheless, in an October 2021 private medical opinion submitted during the 90-day evidence submission period, Dr. S.E. (initials used to protect privacy), opined that the Veteran's current hypertension was at least as likely as not due to or the result of his service-connected PTSD.  He indicated that he had reviewed the evidence of record and considered relevant medical literature, and he noted that the Veteran used smoking and food as coping mechanism when he is anxious or stressed.

There is no medical opinion showing otherwise.  In fact, the Veteran was not afforded a VA examination in connection with his claim for service connection for hypertension claim.

Based on the foregoing and resolving any reasonable doubt in favor of the Veteran, the Board concludes that he is entitled to service connection for hypertension.  

Diabetes Mellitus

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is entitled to service connection for diabetes mellitus.

The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of or symptoms of diabetes mellitus, and he was not diagnosed with the disorder to a compensable degree within one year of his separation from service. 

Nevertheless, in an October 2021 private medical opinion submitted during the 90-day evidence submission period, Dr. S.E. opined that the Veteran's diabetes mellitus was at least as likely as not due to or the result of his service-connected PTSD.  Specifically, he noted that the Veteran was using smoking and food to cope with his PTSD symptoms and this his low energy caused by his PTSD had kept him physically inactive.  Dr. S.E. also cited to medical literature regarding an association between weight gain, smoking, and PTSD.  Therefore, he opined that the Veteran's diabetes mellitus was proximately caused by his service-connected PTSD.  

There is no medical opinion showing otherwise
 one year of his separation from service. 

Nevertheless, in an October 2021 private medical opinion submitted during the 90-day evidence submission period, Dr. S.E. opined that the Veteran's diabetes mellitus was at least as likely as not due to or the result of his service-connected PTSD.  Specifically, he noted that the Veteran was using smoking and food to cope with his PTSD symptoms and this his low energy caused by his PTSD had kept him physically inactive.  Dr. S.E. also cited to medical literature regarding an association between weight gain, smoking, and PTSD.  Therefore, he opined that the Veteran's diabetes mellitus was proximately caused by his service-connected PTSD.  

There is no medical opinion showing otherwise.  In fact, the Veteran was not afforded a VA examination in connection with his claim for service connection for diabetes mellitus.

Based on the foregoing and resolving any reasonable doubt in favor of the Veteran, the Board concludes that the Veteran is entitled to service connection for diabetes mellitus.  

Stroke, Visual Field Defect, Dysarthria, Dysphagia, and Left-Sided Weakness

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is entitled to service connection for a stroke, visual field defect, dysarthria, dysphagia, and left-sided weakness.

The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of a stroke, visual field defect, dysarthria, dysphagia, and left-sided weakness

Nevertheless, in an October 2021 private medical opinion filed during the 90-day evidence submission period, Dr. S.E. noted that the Veteran had multiple strokes with resulting visual problems, speech impairment, and left-sided weakness.  He cited to medical research showing an association between hypertension, diabetes, mellitus, and strokes.  He opined that it is as likely as not that the Veteran's mental health, high blood pressure, and diabetes mellitus type II each contributed to the cause of his cerebrovascular accident. 

VA treatment records also show that the Veteran has had visual problems, dysarthria, dysphagia, and left side-weakness as residuals of a stroke.  The Board acknowledges that July 2018, November 22018, and April 2019 VA treatment records indicated that there was no dysphagia; however, there are other VA treatment records documenting the presence of the disorder. See e.g., April 2018 VA treatment record.  The Board notes that the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even in cases where the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013).

There is no medical opinion showing otherwise.  Indeed, the Veteran was not afforded a VA examination in connection with these claims.

Based on the foregoing and resolving any reasonable doubt in favor of the Veteran, the Board finds that the Veteran is entitled to service connection for a stroke with residual visual field defect, dysarthria, dysphagia, and left-sided weakness.

Erectile Dysfunction

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for erectile dysfunction.

The AOJ made a favorable finding that the Veteran was diagnosed with erectile dysfunction, which is binding on the Board.  

Nevertheless, the Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of erectile dysfunction.  

Moreover, prior to the July 2019 rating decision, the Veteran and his representative did not identify any disease, injury, or event in service to which his erectile dysfunction may be related or otherwise identify a theory of entitlement.  Rather, they filed a claim for service connection for erectile dysfunction without indicating any basis.  There was also no other evidence showing or suggesting the etiology of the disorder. See 38 C.F.R. § 3.159(c)(4)(i); cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease); Waters v. Shinseki, 601 F.3d 
 also no other evidence showing or suggesting the etiology of the disorder. See 38 C.F.R. § 3.159(c)(4)(i); cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (a veteran's mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide a VA examination).

Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran's claim for service connection for erectile dysfunction.  As such, the benefit of the doubt provision does not apply.  Accordingly, the Board concludes that service connection is not warranted.

Earlier Effective Date

Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a).  The effective date for an award of service connection is the day following separation from active service or the date entitlement arose, if the claim is received within one year after separation from service; otherwise, the effective date is the later of the date of receipt of the claim or the date entitlement to service connection arose. 38 C.F.R. § 3.400(b)(2).

The effective date based on the submission of new and material evidence received after a final disallowance is the date of the receipt of the new claim. 38 C.F.R. §§ 3.400(q)(2), 3.400(r).  The effective date for the grant of service connection following a final decision is the date of the reopened claim. See Sears v. Principi, 16 Vet. App. 244, 248 (2002) (holding that 38 U.S.C. § 5110 (a) "is clear on its face with respect to granting an effective date for an award of VA periodic monetary benefits no earlier than the date that the claim for reopening was filed"). The United States Court of Appeals for Veterans Claims (Court) explained that the statutory framework does not allow for the Board to reach back to the date of the original claim as a possible effective date for an award of service-connected benefits based on a reopened claim. Id. (holding that the term "new claim," as it appeared in 38 C.F.R. § 3.400(q), means a claim to reopen a previously and finally decided claim).

Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form.  The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant's effective date of benefits must be received in one of three specified formats.  The amendments also eliminate the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims to reopen under 38 C.F.R. § 3.157. See 79 Fed. Reg. 57,660 (Sept. 25, 2014) (now codified at 38 C.F.R. §§ 3.1(p), 3.151, 3.155).  

Under the former regulations prior to March 24, 2015, a specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a).  The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p).  Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim.  Such informal claim must identify the benefit sought.  Upon receipt of an informal claim, if a formal claim has not been filed, an application form will
 to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a).  The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p).  Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim.  Such informal claim must identify the benefit sought.  Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a).  To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992).  A "pending claim" is defined as an application, formal or informal, which has not been finally adjudicated. 38 C.F.R. § 3.160(c).

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits.  VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to an effective date prior to May 4, 2018, for the grant of service connection for PTSD.

The AOJ previously denied a claim for service connection for depression in a September 2010 rating decision.  The Veteran was notified of that decision and of his appellate rights, but he did not appeal that determination or submit new and material evidence within one year of its issuance.  Therefore, the September 2010 rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.302, 20.1103.

Thereafter, the Veteran first submitted a claim for service connection for PTSD on May 4, 2018.  The record does not contain any earlier communication or correspondence indicating an intent to file a claim for service connection for PTSD.  The Veteran and his representative have also not contended otherwise. See Brannon v. West, 12 Vet. App. 32, 35 (1998) (holding that before VA can adjudicate a claim for benefits, "the claimant must submit a written document identifying the benefit and expressing some intent to seek it"); see also Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995).

Based on the foregoing, the effective date for an award based on an original claim (i.e., the first claim filed for that benefit) cannot be earlier than the date of VA's receipt of the claim.  The date of receipt of the claim is the effective date currently assigned in this case.  As the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply, and the appeal is denied.

Increased Evaluation

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.  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.  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. 38 C.F.R. § 4.7.

In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41.  Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present.
 from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.  Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7.

In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41.  Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present.  38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings.

Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required.  Fenderson v. West, 12 Vet. App. 119, 125-26 (1999).  Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time.  Fenderson, 12 Vet. App. at 126-27.

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits.  VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other).

The Veteran's service-connected PTSD is currently assigned a 70 percent evaluation, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411.  

Under Diagnostic Code 9411, a 70 percent evaluation is assigned when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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 worklike setting); and the inability to establish and maintain effective relationships.

A 100 percent evaluation is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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.

The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002).  It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings.  Id.  The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation.  Id. 

In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity
 even some, of the enumerated symptoms recited for particular ratings.  Id.  The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation.  Id. 

In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration."  It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas."

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is entitled to a higher evaluation for his service-connected PTSD.

The Board acknowledges that the June 2018 and April 2019 VA examination reports do not support entitlement to an evaluation in excess of 70 percent based on the identified symptoms and resulting impairment.  However, those reports also show that the Veteran had had four prior suicide attempts with longstanding passive suicidal ideation, which suggests that he may be in persistent danger of hurting himself.  He has also reported being fearful in public, has been found to have difficulty in establishing and maintaining effective work or social relationships, and has been unemployed.  In addition, an August 2018 VA examiner found that he had mental competency issues, including a finding that he was not capable of managing his financial affairs.  The April 2019 VA examiner further commented that Veteran's strokes had reduced his ability to cope with his PTSD symptoms.  

Moreover, in an October 2021 statement, the Veteran's ex-wife and caregiver, S.B., reported that he experiences panic around others and described self-isolating behavior.  She also discussed his prior suicide attempts and noted that, when he was working, the Veteran was stressed and anxious around others.  In addition, S.B. indicated that she has to assist him with his hygiene and grooming, noting that he sometimes refuses to brush his teeth, shower, and shave.  Such a statement also suggests that the Veteran may have an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene) due to his service-connected PTSD.

Based on the foregoing, the Board finds that there is reasonable doubt as to whether the Veteran more nearly approximates total occupational and social impairment.  As previously noted, there is evidence suggesting persistent danger of hurting himself and an intermittent inability to perform maintenance of minimal personal hygiene.  He is also not working and has been shown to have social isolation.  Thus, resolving any reasonable doubt in his favor, the Board concludes that a 100 percent evaluation is warranted.

SMC

A veteran may receive SMC either by reason of being housebound or based on the need for regular aid and attendance, but may not receive both simultaneously; regular aid and attendance is the greater monetary award.  Compare 38 U.S.C. § 1114 (l) with 38 U.S.C. § 1114 (s). 

SMC based on aid and attendance is payable if, as the result of service-connected disability, the veteran has an anatomical loss or loss of use of both feet, or of one hand and one foot; has blindness in both eyes with visual acuity of 5/200 or less; is permanently bedridden; or is so helpless as to be in need of regular aid and attendance of another person.  38 U.S.C. §§ 1114(l); 38 C.F.R. § 3.350.  Aid and attendance means helplessness or being so nearly helpless as to require the regular aid and attendance of another person.  See 38 C.F.R. § 3.350(b)(3). 

Determinations as to need for aid and attendance must be based on actual requirement of personal assistance from others. In making such determinations, consideration is given to such conditions as: inability to dress or undress himself or keep himself ordinarily clean and presentable, frequent need for adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid, inability to feed himself through loss of coordination of upper extremities or through weakness, inability to attend to the wants of nature, or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the individual from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352; see also Turco v. Brown, 9 Vet. App.
 be based on actual requirement of personal assistance from others. In making such determinations, consideration is given to such conditions as: inability to dress or undress himself or keep himself ordinarily clean and presentable, frequent need for adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid, inability to feed himself through loss of coordination of upper extremities or through weakness, inability to attend to the wants of nature, or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the individual from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352; see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that at least one factor listed in section 3.352(a) must be present for a grant of special monthly compensation based on need for aid and attendance). 

"Bedridden" will be a proper basis for the determination of being so helpless as to require regular aid and attendance of another and is defined as that condition which, through its essential character, actually requires that the claimant remain in bed.  Id.  It is not required that all of the disabling conditions enumerated above be found to exist before a favorable rating may be made.  Id.  The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole.  It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need.  Id.  Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely on an opinion that the claimant's condition is such that it would require him to be in bed.  They must be based on the actual requirements of personal assistance from others.  Id.  

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is entitled to SMC based on the need for regular aid and attendance.

The Veteran is currently service-connected for PTSD (evaluated as 100 percent disabling), bilateral hearing loss (evaluated as 10 percent disabling), and tinnitus (evaluated as 10 percent).  Thus, his combined evaluation is 100 percent.   

The Board has also granted entitlement to service connection for other disabilities in this decision, including hypertension, diabetes mellitus, and residuals of a stroke.  Although the AOJ must effectuate those grants and assign an initial evaluation for those disabilities, the Board finds that there is sufficient evidence to adjudicate the issue of entitlement to SMC based on consideration of his service-connected disabilities.  There is also no prejudice in proceeding with adjudication given the full grant of the benefit sought on appeal.

Notably, a June 2018 disability benefits questionnaire (DBQ) indicated that the Veteran required help with medication management, preparing meals, and attending to activities of daily living.  It was also noted that he was legally blind.  

In addition, an August 2018 VA examiner found that Veteran cannot drive and that he is unable to travel beyond his domicile.  Although he was noted as being able to feed himself, the examiner commented that the Veteran's caregiver has to cut up his food first.  It was also noted that he requires assistance with preparing meals, showering, bathing, shaving, tying his shoes, and dressing and that he was not capable of managing his own medications or finances.  Additionally, the examiner specifically found that the Veteran was not capable of performing self-care, including grooming, dressing and undressing, and bathing; requires a cane for ambulation; and has a lack of coordination due to weakness in left leg. 

Moreover, in an October 2021 statement, S.B. reported being the Veteran's caregiver with whom he lives and outlined the assistance that she provides him on a regular basis.  

The Board finds that the evidence of record persuasively shows that the Veteran requires the need of regular aid and attendance of another person.  Indeed, the evidence clearly indicates that he needs assistance with his activities of daily living and transportation.  Thus, the Board finds that the Veteran requires the regular aid and attendance of another person due to his service-connected disabilities, particularly his residuals of a stroke.  Accordingly, the appeal for entitlement to SMC based on the need for regular aid and attendance is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

 

J.W. ZISSIMOS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Rideout-Davidson, B.

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
 his activities of daily living and transportation.  Thus, the Board finds that the Veteran requires the regular aid and attendance of another person due to his service-connected disabilities, particularly his residuals of a stroke.  Accordingly, the appeal for entitlement to SMC based on the need for regular aid and attendance is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

 

J.W. ZISSIMOS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Rideout-Davidson, B.

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.