Case A26040577

Summary

The veteran, who served from July 1995 to August 1999, appeals the denial of an earlier effective date for a 70 percent rating for posttraumatic stress disorder (PTSD). The case was remanded by the Court of Appeals for Veterans Claims due to the Board's inadequate discussion of the veteran's June 6, 2023, lay statement, which included reports of suicidal thoughts. The Board reviewed evidence up to the September 2023 supplemental claim decision. The veteran's PTSD was rated at 50 percent prior to June 16, 2023. An August 2022 VA examination noted symptoms like isolation, poor hygiene, memory issues, and irritability, but the veteran was oriented and denied suicidal ideation. Subsequent treatment records through January 2023 showed improvement. However, the veteran's June 6, 2023, lay statement reported poor hygiene, difficulty with friendships, judgment, communication, absenteeism, emotional outbursts, problem-solving issues, and suicidal thoughts. The Board found the June 6, 2023, statement and the June 16, 2023, VA examination probative, particularly regarding hygiene, social interaction, judgment, and suicidal thoughts, finding these symptoms were factually ascertainable by June 6, 2023. Resolving doubt in the veteran's favor, the Board granted an effective date of June 6, 2023, for the 70 percent PTSD rating.

Rationale

June 6, 2023, lay statement found probative for hygiene, friendships, judgment, communication, absenteeism, emotional outbursts, problem-solving, and suicidal thoughts.; Contemporaneous August 2022 and June 2023 VA examinations corroborate portions of the lay statement, showing isolation, poor hygiene, memory impairment, and difficulty with relationships and stress adaptation.; Resolving reasonable doubt in the veteran's favor, the Board found the increase in PTSD severity was factually ascertainable by June 6, 2023.

Full Decision Text

Citation Nr: A26040577
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 240509-440157
DATE: April 30, 2026

ORDER

Entitlement to an effective date of June 6, 2023, for the grant of a 70 percent rating for posttraumatic stress disorder (PTSD) is granted.

FINDINGS OF FACT

1. The current appeal stems from a July 2022 intent to file and an August 2022 claim for a total disability rating based on individual unemployability (TDIU), which VA also treated as a claim for increased compensation for PTSD, and the Veteran continuously pursued that matter thereafter.

2. Resolving reasonable doubt in the Veteran's favor, the June 6, 2023, lay statement, when read together with the contemporaneous August 2022 and June 2023 VA examination findings and the remaining evidence of record, establishes that it was factually ascertainable on June 6, 2023, that the Veteran's PTSD had increased to a level more nearly approximating occupational and social impairment with deficiencies in most areas.

CONCLUSION OF LAW

The criteria for an effective date of June 6, 2023, for the grant of a 70 percent rating for PTSD are met.  38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.2500, 3.400, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411, 20.301.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty from July 1995 to August 1999.

This case is before the Board of Veterans' Appeals (Board) following a December 2025 United States Court of Appeals for Veterans Claims (Court) remand of an April 2025 Board decision.

In December 2022, the Veteran submitted a Department of Veterans Affairs (VA) Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a November 2022 decision, following an August 2022 application for increased compensation based on unemployability, received within one year of a July 2022 intent to file.

In March 2023, the agency of original jurisdiction (AOJ) issued an HLR decision, which considered the evidence of record at the time of the prior November 2022 decision.

In March 2023, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, seeking a rating higher than 50 percent for PTSD, most recently addressed in the March 2023 HLR decision.

In March 2023, the AOJ issued a supplemental claim decision, finding new and relevant evidence but denying the claim based on the evidence of record at the time of that decision.

In June 2023, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, seeking a rating higher than 50 percent for PTSD, most recently addressed in the March 2023 supplemental claim decision.

In September 2023, the AOJ issued a supplemental claim decision, granting an evaluation of 70 percent for PTSD effective June 16, 2023, the date of the June 2023 VA examination.

In October 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, and requested review of the September 2023 supplemental claim decision.

In March 2024, the AOJ issued an HLR decision, which considered the evidence of record at the time of the prior September 2023 supplemental claim decision.

The Veteran elected the Direct Review docket in the May 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement).

In an April 2025 decision, the Board denied the claim of an earlier effective date for PTSD.  The Veteran appealed the denial to the Court, which vacated the Board's April 2025 decision in a December 2025 Order.  In an accompanying Joint Motion for Partial Remand (JMPR), the parties agreed that the Board failed to provide an adequate statement of reasons or bases for its findings.

Specifically, the parties agreed that the Board did not adequately discuss the Veteran's June 6, 2023, lay statement, including the checked report of "suicidal thoughts or feelings, not caring if you live or die," in denying an effective date earlier than June 16, 2023, for the award of a 70 percent evaluation for PTSD.

The Board notes that entitlement to an effective date earlier than June 16
 appealed the denial to the Court, which vacated the Board's April 2025 decision in a December 2025 Order.  In an accompanying Joint Motion for Partial Remand (JMPR), the parties agreed that the Board failed to provide an adequate statement of reasons or bases for its findings.

Specifically, the parties agreed that the Board did not adequately discuss the Veteran's June 6, 2023, lay statement, including the checked report of "suicidal thoughts or feelings, not caring if you live or die," in denying an effective date earlier than June 16, 2023, for the award of a 70 percent evaluation for PTSD.

The Board notes that entitlement to an effective date earlier than June 16, 2023, for the award of a TDIU is not presently before the Board.  The JMPR reflects that the Veteran declined to continue the appeal on that issue, and the Court dismissed the earlier effective date issue for a TDIU.  Thus, the only matter remaining for appellate consideration is entitlement to an earlier effective date for the grant of a 70 percent rating for PTSD.

Because this appeal is in the Direct Review docket, the Board may only consider the evidence of record at the time of the September 2023 supplemental claim decision.  38 C.F.R. § 20.301.  The Board cannot consider any evidence submitted after the September 2023 supplemental claim decision.  38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any submitted evidence that the Board could not, the Veteran 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 claims, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision.

Entitlement to an effective date prior to June 16, 2023, for the grant of a 70 percent rating for PTSD.

Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  Separate diagnostic codes identify the various disabilities.  Although the Board typically considers only those factors contained wholly in the rating criteria, the Board must consider factors outside the specific rating criteria to determine the level of occupational and social impairment.  See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208.  

Where there is a question as to which of two evaluations shall be applied, VA will assign the higher evaluation if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, it will assign the lower rating.  38 C.F.R. § 4.7.  VA resolves any reasonable doubt regarding the degree of disability in favor of the Veteran.  38 C.F.R. § 4.3. 

The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b).  Under that provision, VA shall consider all information, including lay and medical evidence of record in a case before the Secretary concerning benefits under laws the Secretary administers.  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); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

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).

The Veteran is competent to report symptoms and experiences observable by his senses.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). 

Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms.
ation 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).

The Veteran is competent to report symptoms and experiences observable by his senses.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). 

Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms.  "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration."  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013).  VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5).  See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002).  VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the claimant's service-connected mental disorder, quantifies the level of occupational and social impairment those signs and symptoms cause, and assigns an evaluation that most nearly approximates that level of occupational and social impairment.  Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017).

The Veteran's service-connected PTSD is rated as 50 percent disabling prior to June 16, 2023, under 38 C.F.R. § 4.130, Diagnostic Code 9411.

Under the General Rating Formula, a 30 percent evaluation is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks, weekly or less often; chronic sleep impairment; and mild memory loss.  38 C.F.R. § 4.130, Diagnostic Code 9411.

A 50 percent rating is warranted if claimant suffers occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  Id.  

In order to warrant a 70 percent rating, the evidence must show 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; obsessive 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 an inability to establish and maintain effective relationships.  Id. 

A 100 percent rating is warranted when total occupational and social impairment is 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; memory loss for names of close relatives, own occupation, or own name.  Id.

When evaluating the level of disability from a mental disorder, the rating agency will consider all evidence holistically and not assign an evaluation solely based on a single factor.  See 38 C.F.R. § 4.126.

A review of the record demonstrates that the Veteran's PTSD warrants a 70 percent rating as of June 6, 2023.

During an August 2022 VA examination, the Veteran reported continued isolation, a brother who served as nearby social support, strained relationships with others, and a history of having only a few relationships due to shyness.  He further reported attendance problems at work, bathing and grooming only one day per week due to lack of motivation, forgetting appointments
, or own name.  Id.

When evaluating the level of disability from a mental disorder, the rating agency will consider all evidence holistically and not assign an evaluation solely based on a single factor.  See 38 C.F.R. § 4.126.

A review of the record demonstrates that the Veteran's PTSD warrants a 70 percent rating as of June 6, 2023.

During an August 2022 VA examination, the Veteran reported continued isolation, a brother who served as nearby social support, strained relationships with others, and a history of having only a few relationships due to shyness.  He further reported attendance problems at work, bathing and grooming only one day per week due to lack of motivation, forgetting appointments, leaving things in the oven, and misplacing keys.  The examiner observed the Veteran to be dressed sloppily, with limited short-term memory, and documented symptoms including intrusive thoughts, distressing dreams, avoidance behavior, persistent negative emotional state, markedly diminished interest, feelings of detachment, irritable behavior or angry outbursts, hypervigilance, sleep disturbance, depressed mood, anxiety, suspiciousness, and chronic sleep impairment.

The August 2022 VA examination also showed that the Veteran was alert and oriented in all spheres, cooperative, logical, and organized in thought.  There was no evidence of hallucinations or delusions, and no suicidal or homicidal ideation.  Insight and judgment were described as good or fair.  Immediate and remote memory were intact.  The examiner determined that the Veteran's PTSD symptoms resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication.  The examiner found the Veteran could perform one to two-step tasks, might be overwhelmed by more complex tasks, might struggle to get along with coworkers, but remained able to perform physical and sedentary jobs and could plan a typical workweek.

An October 2022 VA treatment note shows that the Veteran reported depression and displayed a flattened affect, but his mental status examination was otherwise normal.  In December 2022, he reported not having symptoms of depression, anxiety, or mania, denied psychosis, and had an otherwise normal mental status examination aside from irritable affect.  In January 2023, he reported progress in symptoms, including being able to shop, go to the gym, and be around others, and that his symptoms seemed more manageable.  He also reported positive coping strategies, supportive family or friends, plans for the future, no loss of purpose or direction, and no sleep problems, and he was assessed as having a low risk of suicide.

In a June 6, 2023, correspondence, the Veteran submitted a mental-disorder symptom form on which he checked symptoms, including poor personal hygiene, inability to make or keep friends, inability to make judgments in a timely manner, communication problems, and "suicidal thoughts or feelings, not caring if you live or die."  He also separately reported that his psychiatric symptoms caused absenteeism, emotional outbursts, and difficulty problem-solving when attention was low.

The Board notes that the June 2023 VA examination showed occupational and social impairment with reduced reliability and productivity due to PTSD symptoms of intrusive thoughts, distressing dreams, intense and prolonged psychological distress and marked psychological reactions, avoidance behavior, persistent and exaggerated negative beliefs, markedly diminished interest, feelings of detachment, persistent inability to experience positive emotions, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, suspiciousness, panic attack once a week, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbance of mood and motivation, difficulty establishing and maintaining relationships and adapting to stressful circumstances, and neglect of personal appearance and hygiene.  The VA examiner observed that the Veteran had a tense demeanor, a clenched jaw, casual clothing with a dirty t-shirt, normal speech, and was fully engaged, forthcoming, and expansive, but his answers were terse.  The Veteran denied suicidal ideation during the examination.

The Board finds the Veteran competent to report observable psychiatric symptoms and their functional effects.  The Board further finds the June 6, 2023, lay statement probative in part.  Specifically, the Board finds probative the reports of poor personal hygiene, inability to make or keep friends, inability to make judgments in a timely manner, communication problems, absenteeism, emotional outbursts, difficulty problem-solving when attention was low, and suicidal thoughts.  These reports are materially consistent with the August 2022 VA examination documenting isolation, strained relationships, attendance problems, bathing and grooming only one day a week, sloppy dress, limited short-term memory, irritability or angry outbursts, and depressed mood, and with the June 16, 2023, VA examination documenting no
 observable psychiatric symptoms and their functional effects.  The Board further finds the June 6, 2023, lay statement probative in part.  Specifically, the Board finds probative the reports of poor personal hygiene, inability to make or keep friends, inability to make judgments in a timely manner, communication problems, absenteeism, emotional outbursts, difficulty problem-solving when attention was low, and suicidal thoughts.  These reports are materially consistent with the August 2022 VA examination documenting isolation, strained relationships, attendance problems, bathing and grooming only one day a week, sloppy dress, limited short-term memory, irritability or angry outbursts, and depressed mood, and with the June 16, 2023, VA examination documenting no social network, memory impairment, difficulty establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, and neglect of personal appearance and hygiene.

The Board, however, does not find every checked item on the June 6, 2023, form equally persuasive.  In particular, the overall record does not support the checked reports suggesting the Veteran was a danger to himself or others, disoriented, manic, or illogical in thinking.  Throughout the period on appeal, including at the August 2022 and June 2023 VA examinations, the Veteran was observed to be oriented, cooperative, and logical, with no hallucinations or delusions.  The Board, therefore, assigns reduced probative weight to those particular checked items.  Even so, the Board does not reject the entire June 6, 2023, correspondence.  Rather, considering the credible portions of that statement together with the contemporaneous medical evidence, and resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas as of June 6, 2023.  Especially as the June 16, 2023, VA examination strongly corroborates portions of the Veteran's June 6, 2023, correspondence, made only ten days prior to the June 2023 VA examination.  The Board finds the June 2023 VA examination, together with the June 6, 2023, correspondence and the August 2022 findings, confirms that the increase in severity was factually ascertainable by June 6, 2023.

The Board has also considered whether an effective date earlier than June 6, 2023, is warranted.  Although the August 2022 examination documented some symptoms that resemble those listed in the 70 percent criteria, the overall disability picture prior to June 6, 2023, did not more nearly approximate deficiencies in most areas.  The Veteran remained oriented and logical, denied suicidal ideation, retained some supportive relationships, and treatment records through January 2023 reflected improvement and manageable symptoms.  The Board therefore finds that June 6, 2023, is the earliest date on which it became factually ascertainable that the criteria for a 70 percent rating were met.

Resolving reasonable doubt in the Veteran's favor, the June 6, 2023, correspondence, when read together with the contemporaneous August 2022 and June 2023 VA examination findings and treatment records, establishes that it was factually ascertainable on June 6, 2023, that the Veteran's PTSD had increased to a level more nearly approximating occupational and social impairment with deficiencies in most areas.

An effective date of June 6, 2023, for the grant of a 70 percent rating for PTSD is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.  The claim is granted.

 

 

R. FEINBERG

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Costa, Stephanie D.

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.