Citation Nr: 0001816 Decision Date: 01/21/00 Archive Date: 01/28/00 DOCKET NO. 93-04 742 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an increased (compensable) evaluation for shell fragment wound scar, left lateral chest area. 2. Entitlement to an increased (compensable) evaluation for shell fragment wound scar, left posterior chest area. 3. Entitlement to a total disability rating based on individual unemployability (IU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse INTRODUCTION The veteran had active military service from April 1970 to December 1971, and from May 1977 to April 1986. This case was previously before the Board and remanded for additional development in January 1994, and April 1996. The case was returned to the Board for further appellate consideration. The Board in November 1997 remanded the issues of entitlement to a compensable evaluation for scars of the left posterior and lateral chest, and entitlement to IU benefits. The case has recently been returned to the Board for appellate consideration of these issues FINDINGS OF FACT 1. The veteran without good cause failed to report for a VA medical examination that was necessary for a determination of his claim for increased evaluation for residuals, shell fragment wound scars of the left lateral chest area and the left posterior chest area. 2. The veteran has completed the equivalent of a high school education; he last worked in 1988 as a laborer and has reported no other occupational training of significance. 3. The veteran's service-connected disabilities, principally PTSD, when evaluated in association with his educational attainment and occupational experience, are sufficiently disabling to render him unable to obtain and retain all kinds of substantially gainful employment. CONCLUSIONS OF LAW 1. The veteran's claims for increase for residuals, shell fragment wound scars of the left lateral chest area and the left posterior chest area are denied as a matter of law. 38 C.F.R. 3.655 (1999). 2. The criteria for to a total compensation rating based on IU have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Evaluation for scars, left posterior chest and left lateral chest. Factual Background The RO in June 1972 considered service medical records and a contemporaneous VA examination when it granted service connection for shell fragment wound scars of the lateral and posterior chest. The RO assigned a noncompensable rating under Diagnostic Code 7805 criteria. A VA examiner reported two punctate wounds of the left chest posterior to the level of the seventh interspace, two inches in length, that were not fixed and without muscle loss. The diagnosis was shell fragment wound of the left thorax. A VA examiner in April 1992 found two scars of the left mid posterior thorax, both dime sized. The scar nearest the midline was depressed, nonadherent and nontender. The other scar was nondepressed, nonadherent and nontender. The diagnosis was shell fragment wound scars, left posterior chest area. The Board in January 1994 and April 1996 asked for an examination to evaluate the veteran's wound scar residuals but the scars of the chest were not evaluated on VA examinations in 1994 and 1996. The Board in November 1997 once again asked for an examination. The record shows that the veteran provided his current address in correspondence to the RO in January 1998. The RO requested examinations of muscle and respiratory systems and skin other than scars. He was advised by letter in December 1998 that examinations were scheduled on two days in January 1999. The letter informed him that it was essential to report and that failure to do so may adversely affect his current or potential benefits. He was advised that the examinations were scheduled in connection with a claim for disability benefits. The record shows that the veteran did not report for the scheduled examinations. He and his representative were advised of the failure to report and the effect upon the consideration of his claim for increase in a supplemental statement of the case issued in March 1999. Criteria 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 percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Both the use of manifestations not resulting from service- connected disease or injury in establishing the service- connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation, see 38 C.F.R. §§ 4.2, 4.41 (1998), the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. On a claim for an original or an increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, 38 (1993). Scars, superficial, poorly nourished, with repeated ulceration shall be rated as 10 percent disabling. Diagnostic Code 7803. Scars, superficial, tender and painful on objective demonstration shall be rated as 10 percent disabling. Diagnostic Code 7804. The 10 percent rating will be assigned, when the requirements are met, even though the location may be on tip of finger or toe, and the rating may exceed the amputation value for the limited involvement. Note following Diagnostic Code 7804. Scars, other, shall be rated on limitation of function of part affected. Diagnostic Code 7805. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3. Regulations provide that when entitlement to a benefit cannot be established without a current VA examination, and a claimant, without good cause, fails to report for such examination, the claim shall be denied. 38 C.F.R. § 3.655(a)(b) (1998). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. Id. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be based on the evidence of record. Id. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit, which was previously disallowed, or a claim for increase, the claim shall be denied. Id. Every claimant has the right to written notice of the decision made on his or her claim, the right to a hearing, and the right of representation. Proceedings before VA are ex parte in nature, and it is the obligation of VA to assist a claimant in developing the facts pertinent to the claim and to render a decision that grants every benefit that can be supported in law while protecting the interests of the Government. 38 C.F.R. § 3.103. Notice means written notice sent to a claimant or payee at his or her latest address of record. 38 C.F.R. § 3.1(q). (a) Where there is a well-grounded claim for disability compensation or pension but medical evidence accompanying the claim is not adequate for rating purposes, a Department of Veterans Affairs examination will be authorized. This paragraph applies to original and reopened claims as well as claims for increase submitted by a veteran, surviving spouse, parent, or child. Individuals for whom an examination has been scheduled are required to report for the examination. (b) Provided that it is otherwise adequate for rating purposes, any hospital report, or any examination report, from any government or private institution may be accepted for rating a claim without further examination. However, monetary benefits to a former prisoner of war will not be denied unless the claimant has been offered a complete physical examination conducted at a Department of Veterans Affairs hospital or outpatient clinic. (c) Provided that it is otherwise adequate for rating purposes, a statement from a private physician may be accepted for rating a claim without further examination. 38 C.F.R. § 3.326. Reexaminations, including periods of hospital observation, will be requested whenever VA determines there is a need to verify either the continued existence or the current severity of a disability. Generally, reexaminations will be required if it is likely that a disability has improved, or if evidence indicates there has been a material change in a disability or that the current rating may be incorrect. Individuals for whom reexaminations have been authorized and scheduled are required to report for such reexaminations. Paragraphs (b) and (c) of this section provide general guidelines for requesting reexaminations, but shall not be construed as limiting VA's authority to request reexaminations, or periods of hospital observation, at any time in order to ensure that a disability is accurately rated. 38 C.F.R. § 3.327. In the consideration of appeals, the Board is bound by applicable statutes, regulations of the Department of Veterans Affairs, and precedent opinions of the General Counsel of the Department of Veterans Affairs. The Board is not bound by Department manuals, circulars, or similar administrative issues. 38 C.F.R. § 19.5. The United States Court of Appeals for Veterans Claims (Court) has held that the burden was upon VA to demonstrate that notice was sent to the claimant's last address of record and that the claimant lacked adequate reason or good cause for failing to report for a scheduled examination. Hyson v. Brown, 5 Vet. App. 262, 265 (1993). The Court has also held that the "duty" to assist is not always a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Court has held that claim denials based upon 38 C.F.R. § 3.655 for failure to report for a scheduled VA examination without good cause are factual matters which are subject to a "clearly erroneous" standard of review. Engelke v. Gober, 10 Vet. App. 396, 399 (1997). In the absence of clear evidence to the contrary, the law presumes the regularity of the administrative process. Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994) (citing Ashley v. Derwinski, 2 Vet. App. 62, 64-65 (1992)) (citing to United States v. Chemical Foundation, Inc., 272 U.S. 1, 14- 15, 47 S.Ct. 1, 6, 71 L.Ed. 131 (1926)). Notification for VA purposes is a written notice sent to the claimant's last address of record. 38 C.F.R. § 3.1(q). Analysis The Board has reviewed the record in light of the recent decision of the Court in Stegall v. West, 11 Vet. App. 268 (1998). In view of the recent legal precedent in Stegall as applied to the facts of this appeal, and other applicable legal precedent discussed below, it is the opinion of the Board that the case should not again be remanded for further action. The Board has not overlooked the basic regulatory criteria for entitlement to increased ratings recited above. However, the determinative factor in the decision to deny the claim does not rest upon the merits. Rather, the unexplained failure of the veteran to cooperate in the development of the claim made an informed determination of the claim on the merits impossible. The Board is also bound by the regulations that require the claim be denied in such circumstances. Further, the Board finds no need to formally include a determination of well groundedness as a claim for increase accepts an allegation of increased severity as generally sufficient to well ground the claim. The Board's development of the claim by remand was designed to insure that the record was adequate for an informed determination. 38 C.F.R. §§ 3.326, 3.327. The evidence initially presented to the Board was comprehensive but most of the information focused upon the superficial scar residuals. The VA examinations did not appear to account for all potentially disabling conditions or functional impairment as a result of the well healed superficial scars. The examinations though early 1992 did not show symptomatic scars to allow for a compensable evaluation under Diagnostic Codes 7803 or 7804. The veteran's failure to cooperate has not been justified. There is no argument from the veteran or his representative regarding good cause for his inaction. The RO conscientiously sought to develop the claim through contact with the veteran at his known address at each stage of the appeal. The veteran was also contacted for a medical examination. His situation is clearly different from that presented in Hyson v. Brown, 5 Vet. App. 262, 265 (1993). The veteran's whereabouts appears established. None of the correspondence addressed to the veteran pursuant to the 1997 remand has been returned as undelivered. 38 C.F.R. § 3.1(q). The Board observes that the veteran was advised by the RO SSOC of the significance of failing to cooperate in that he was told evidence material to the outcome was not available for consideration. The provisions of 38 C.F.R. § 3.655 applicable to the veteran's claim for increase require that his claim be denied rather than being decided on the evidence of record. The distinction between treatment of initial compensation claims and other claims such as the veteran's claim for increase is clear in the regulation. The veteran's inaction without good cause has been noted previously in this discussion. As a result, § 3.655(b) mandates the claim for increase be denied. As mentioned previously, the Board is bound in its decisions by VA regulations but not manual provisions. 38 C.F.R. § 19.5. Although none of the recent RO correspondence was returned as undelivered, the representative has not offered any information indicating that the veteran's current address has changed or that telephone contact was attempted. The record does not show he responded or otherwise advised the representative of a reason for failing to cooperate. Further, the information regarding the scheduling of examinations and contact with the veteran regarding his attendance is complete enough to allow the Board to make an informed determination on the question of whether good cause existed on the failure to report. The veteran's failure to respond to the recently issued SSOC in any manner to indicate he might have had good cause for not reporting allows the Board to reasonably conclude that he was not prejudiced by any omission of a direct reference to § 3.655. The record here contains the essential information for the factual determination of whether there was good cause for the veteran's failure to report. Although arguably distinguishable from the situation in Engelke v. Gober, 10 Vet. App. 396, 399 (1997), the facts of this case appear similar enough and do not appear to justify additional development. For example, there is no evidence to suggest that the veteran's whereabouts are unknown or that he not at his address of record. He was contacted regarding the examination as indicated by the VAMC correspondence. Further, the record indicates there was an attempt through letter contact to insure compliance with the examination. He did not report and neither he nor his representative has offered any reason for the failure to cooperate. Given the presumption of regularity of the mailing of VA examination scheduling notice and considering the fact that the veteran has never contacted the RO to give adequate reasons for not reporting for an examination, the Board is satisfied that the veteran failed to report to the scheduled examination without good cause. 38 C.F.R. § 3.655. Therefore, the Board finds that the veteran's claim for increase must be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. IU Factual Background VA outpatient clinic records show that in May 1988 the veteran's complaints included frequent nightmares of experiences in Vietnam. He admitted to drinking beer every once in a while, and was working as a mechanic. It was noted that he had been increasingly more withdrawn, and his spouse did most of the talking. The impression was depression. The veteran was hospitalized at a VA medical facility in March 1989, with problems of dreams of war and anxiety around strangers after the Grenada invasion. He was having sleep problems, and reported being off alcohol since he started his medications. While hospitalized he underwent psychiatric evaluation. His chief complaint was that being around people made him nervous. Loud noises would make him feel he was in Vietnam and he would see himself being wounded by shrapnel and a buddy blown apart by a land mine. It was noted that he had a GED, watched TV, built models, did household and yard chores, drove his car, shopped, and visited his parents weekly. The veteran's past employment was listed, and it was noted that the veteran felt he was unable to work because he would get nervous around people. On mental status evaluation his speech was normal, and he was relevant and coherent, and he was oriented in 3 spheres. His mood was anxious and depressed and his affect was bland. His judgment and insight were fair. The diagnosis was post-traumatic stress disorder. VA outpatient clinic records show treatment for the veteran in 1989 and 1990. In December 1989, and April 1990 it was noted that the veteran was sleeping well and not depressed with medication. The records received from the Social Security Administration (SSA) show the veteran's claim for disability benefits was not approved in 1988 or 1989 applications. A psychiatric review in late 1990 found slight restriction in daily activities, and slight difficulty in maintaining functioning. There was no deficiency in concentration or episodes of decomposition in the work setting. A medical assessment in early 1991 found severe limitation from anxiety, depression and suicidal ideation and PTSD. The veteran was found to have an emotional disorder that impacted thinking, memory and intelligence. He was felt to have good ability to follow work rules, interact with supervisors, follow simple job instructions and maintain personal appearance. He was considered to have fair ability to relate predictably in a social situation, to demonstrate reliability, complete job instructions, follow detailed but not complex job instructions, function independently or maintain attention and concentration or relate to coworkers and use judgment in public. He was found to have poor or no ability to behave in an emotionally unstable manner, deal with work stress or deal with the public. A psychological evaluation in 1991 showed an impression of major depression with anxiety secondary to PTSD and the recommendation for intensive psychotherapy and vocational rehabilitation. An SSA Administrative Law Judge (ALJ) found in 1991 that the veteran had not engaged in substantial gainful employment, tat the medical evidence established the veteran had severe PTSD with anxiety and depression, and that the severity of the impairments had precluded him from working for a least 12 months, and that he had been under a "disability" as defined for SSA purposes since April 1988. The SSA disability determination decision implementing the ALJ determination listed severe PTSD as the primary diagnosis and anxiety and depression as secondary diagnoses. In an Agent Orange payment program form, dated in February 1991, it was recorded that the veteran had symptoms of intrusive thoughts of traumatic combat experiences, nightmares, flashbacks, social withdrawal, intermittent insomnia, rage episodes, hypervigilance, exaggerated startle response, and emotional lability. Dissociative episodes were also noted. It was remarked that the veteran had chronic anxiety symptoms with autonomic instability. The veteran's spouse, in a statement dated in March 1991, recounted the veteran's overdosing on medication, his problems coping with his children and being around people. In April 1991, the veteran was provided psychological evaluation and testing. The diagnosis was PTSD, chronic, moderate-severe. The veteran underwent VA psychiatric examination in May 1991, and at that time he complained of flashbacks, loud noises nightmares, tight places, and feeling depressed. The diagnoses were PTSD and dysthymia. When hospitalized in November and December 1991, the veteran complaints were: increase in mood swings; increased problems with anger control; increased feelings of rage; recent suicidal ideation with increased depression; anxiety; increased irritability; social withdrawal and isolation; increase in alcohol use in last 2 months as a result of depression; poor sleep with frequent nightmares; poor memory and concentration, and anhedonia. Physical examination showed the veteran's liver to be 10 centimeters by percussion. The identified problems to be addressed while hospitalized were depressive symptoms due to inability to verbalized feelings, and impaired coping with anger and nightmares related to PTSD. At the time of discharge, the veteran appeared more spontaneous with pharmacotherapeutic intervention and he verbalized a decrease in depressive symptoms. The veteran provided testimony before a hearing in February 1992. At that time he reported problems with being in tight places, and being around people, Transcript (T) 2. He reported flashbacks, and at times losing 2 to 3 hours a day, not knowing where he is, T 5. The veteran noted sleep problems, seeking quite places to get away, T 6. A typical day described by the veteran was staying at home, sometimes fishing, sometimes visiting with his father when he would come over, and going for a ride to someplace where there is no one around, T 7. The veteran's spouse also testified as to the veteran's problems with his temper, flashbacks, T 10, 11. VA psychiatric examination was conducted in April 1992. The veteran described his military exploits. He reported quitting alcohol in 1976, stated that now he was nervous all the time, since 1986. Small rooms made him nervous because he spent a lot of time in tunnels in Vietnam, he didn't trust people, and had trouble falling asleep. His flash backs were spontaneous, and involved his shrapnel wounds and a buddy being killed. He no longer hunted or fished, and had bouts of depression. He had lost interest in most things, and would drive around in his car, and watch television. Objectively his mood was depressed, anxious and withdrawn. He affect was appropriated, and his speech was normal, productive, relevant and coherent. His judgment was said to be fair. The diagnoses were PTSD, recurrent major depression, and alcohol abuse in remission. VA outpatient clinic records show treatment for the veteran in 1992, 1993, and 1994. In June 1993 it was noted that in regard to the veteran's anger control problems, he would get mad, and then "avoids/isolates, or gets drunk." The veteran complained of decreased memory (visual and verbal), blank spells and smelling rotten smells for 5 years. Later in June it was noted that he veteran would blank out when angry, and he was having repeated flashbacks so frequently that he could not attend therapy. In late August 1993 the veteran underwent neuropsychological evaluation to evaluate reported visual and verbal memory complaints. The veteran reported failing 4 grades in school starting in the fourth grade. He quite at age 18, in the 9th grade. He had problems with mathematics and grammar. Episodes of head injury in service, and a 105 fever with malaria, in 1972, were reported. The veteran reported consumption of 12 beers daily until 1988 when he began taking psychotropic medication. In the past year he had been drunk 4 times, and drank when he was angry. He endorsed symptoms of increased tolerance and blackouts. On observation the veteran was alert, oriented, generally attentive, and cooperative throughout the testing sessions. His affect was appropriate, and he appeared frustrated by some tasks that were difficult for him. Despite the frustration he was generally persistent on tasks that were difficult and he appeared motivated to do well on the assessment. His current complaints included a reported increase in verbal and visual memory problems over the past 5 years, experiencing periods in which he "blanks out" for a few seconds on a daily basis. Independent of the "blanking out" episodes he also reported flashbacks since Vietnam and olfactory hallucinations of rotten food for the past 5 years. The neuropsychological evaluation was interpreted as showing that in general most performances were consistent with premorbid estimates of overall intellectual functioning. However, his impaired ability to retain information over time raised the question temporal lobe dysfunction. It was noted that while such dysfunction may reflect neurotoxic sequelae of his past substance abuse, his recent reports of "blanking out", olfactory hallucinations, and progression of memory problems deserved further consideration, and acute neuropathology, such as a subclinical presentation of seizure disorder, should be ruled out. It was also noted that this dysfunction was not readily explained by his emotional distress as scores on tasks of attention, concentration, and immediate recall generally fell within normal limits. An outpatient neurology consult in December 1993, noted the veteran's complaints concerning his memory, blanking out, and rotten smells. In March 1994 there was a diagnosis of amnestic dementia, probably pseudodementia of depression. VA psychiatric examination was conducted in March 1994. The veteran complained of nightmares, flashbacks, sleep problems, isolation being nervous around people. On observation the veteran was tanned, cooperative, and pleasant. His mood was euthymic and he admitted to abusing alcohol in the past but now only occasionally drank a beer. His judgment was fair and his insight was limited. The diagnoses were PTSD; alcohol abuse, in remission; major depression, recurrent, in remission; and nicotine dependence. The degree of emotional impairment was said to be moderate. It was noted that the veteran's medication was not felt to impair his industrial adaptability, as the Prozac should improve his performance at work. Mental disorder examination of the veteran in June 1996 reflects complaints of nightmares, anger, memory problems, and difficulty in crowds. It was noted that between the two periods of service the veteran held about 5 or 6 jobs. The veteran reported that it had been about 6 months since he had been in treatment, and he currently was on no medications. The veteran was dressed casually and not well groomed. On observation the veteran offered very limited amount of information and most of it had to be extracted. He admitted to being paranoid all the time and having suicidal thoughts in the past but not now. He stated that mostly he "gets angry." His judgment was said to be poor because of his anger control, and his insight was nil. He admitted to drinking heavily in service, but reported that he had not drunk anything in 4 years. His mood was bland, and recent and remote memory was fair. The veteran's concentration and attention span were mildly impaired. The diagnoses were PTSD; major depression, recurrent, in remission; nicotine dependence; and alcohol abuse, said to be in remission. A GAF (Global Assessment of Functioning Scale) score of 60 was given. A contemporary social and industrial report noted that the report was based on interview with the veteran and his wife, and review of medical reports. It was noted that he veteran handled his frustration with his children by hitting or running to the woods and hiding. He reported feeling anxious around other people and found comfort in isolation. The impression was that the veteran was cooperative, but distant, alert, and oriented in 3 spheres. His recent memory was intact, but remote memory was questionable. His judgment appeared to be fair but his insight was limited, and he appeared to depend on his wife to make decisions for him and his family. When faced with family challenges he would respond in an adolescent manner by temper out burst or withdrawing to the extent of hiding (also characteristic of PTSD). It was noted that he had not held a job for any significant amount of time prior to military service or after. VA psychiatric examination was completed in January 1997. The examiner noted reviewing the veteran's claims file, the evaluations in 1994, and June 1996, and the social and industrial report. It was noted that the veteran only held 2 jobs before service, the longest for about a year. The veteran's complaints included nightmares of Vietnam, doing things he didn't remember doing, going "blank", sleep problems, depression, isolation and nervous around crowds. He handled his anger by leaving. The veteran reported that he had received no treatment since 1994 because he didn't feel that his past treatment had helped. The veteran provided a military and vocational history. He reported that he had not drunk anything since 1987, and the examiner noted that on the last examination the veteran reported not drinking anything in the last 4 years. On mental status evaluation, it was recorded that the veteran had a full beard and looked somewhat unkempt. He was a poor historian and did not give much information, stating that he could not remember, or he had forgotten. He was oriented in 3 spheres, his sensorium was clear and his mood was bland and somewhat empty. He did appear to be particularly depressed, his recent memory was fair, and his remote memory was poor. The veteran stated that he did not trust people but was not particularly paranoid. During the interview the veteran did appear to be particularly depressed and his recent memory was fair, but his remote memory was rather poor. His concentration and attention span were mildly impaired. The veteran denied any current suicidal or homicidal ideation. His judgment was considered to be poor because of his poor anger control and his insight was virtually nil. The diagnoses were PTSD; major depression, recurrent, in remission; nicotine dependence; and alcohol abuse, said to be in remission. The examiner reported a GAF score of 60, explaining that the veteran was moderately impaired. He could work in a low- stress job situation, preferably alone; however, his ability to work with pace, concentration, and persistence, would probably be moderately impaired. His concentration and memory, especially past memory, was poor, and his concentration was limited but only mildly affected. It was recommended that the veteran get involved in treatment. VA outpatient records show in 1998 the veteran was found to be fully oriented with depressed affect and mood, no psychosis and fair insight and judgment and no suicidal or homicidal ideation. The impression was PTSD and major depression without psychotic features. A GAF score of 50 was assigned. A psychiatric review completed in May 1998 for SSA purposes noted the veteran had a well-documented history of PTSD as an outpatient and as an inpatient and that the symptoms affected all aspects of daily living. The examiner reported marked restriction of daily activities and marked difficulty in maintaining social functioning as well as frequent deficiency in concentration with failure to complete tasks. The examiner found continual episodes of deterioration or decompensation in work or a work-like setting. The veteran current receives a 50 percent rating for PTSD, 10 percent ratings for shell fragment wound residuals of the left upper arm and forearm and the right knee, which combine to 60 percent. Noncompensable ratings are in effect for shell fragment wound residual so the posterior chest and right lateral chest and for malaria. Criteria The 1945 Schedule for Rating Disabilities will be used for evaluating the degree of disabilities in claims for disability compensation, disability and death pension, and in eligibility determinations. The provisions contained in the rating schedule will represent as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from disability. 38 C.F.R. § 3.321. Total ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent evaluation or, with less disability, where the requirements of paragraph 16, page 5 of the rating schedule are present or where, in pension cases, the requirements of paragraph 17, page 5 of the schedule are met. 38 C.F.R. § 3.340. Total disability compensation ratings may be assigned under the provisions of § 3.340. However, if the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. The ability to overcome the handicap of disability varies widely among individuals. The rating, however, is based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. However, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effect of combinations of disability. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation: Provided, That permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. The following will be considered to be permanent total disability: the permanent loss of the use of both hands, or of both feet, or of one hand and one foot, or of the sight of both eyes, or becoming permanently helpless or permanently bedridden. Other total disability ratings are scheduled in the various bodily systems of this schedule. 38 C.F.R. § 4.15. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, 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: Provided That, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. It is provided further that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the veteran unemployable. Marginal employment shall not be considered substantially gainful employment. For purposes of this section, marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). It is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation and Pension Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) of this section. The rating board will include a full statement as to the veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Analysis As a preliminary matter, the Board notes that the veteran's claim for IU benefits is, in essence, a claim for increased rating which, in general, is well grounded. The Board is satisfied that all relevant facts have been properly developed and that there is no further duty to assist with respect to the claim. The Board has noted the current posture of the claim and the SSA determination. It would seem reasonable not to delay the claim further as this appeal has been pending for nearly a decade in the appellate review of various issues. Stegall, supra. The claim for IU, in general, is not inextricably intertwined with an increased rating claim, as an individual unemployability claim does not necessarily require a specific disability rating for consideration. Vettese v. Brown, 7 Vet. App. 31 (1994). The relevant facts show that the veteran completed several years of high school and has completed a GED and last worked in the late 1988 as a laborer. He was granted SSA disability benefits in 1991. Regarding the veteran's compensable service-connected disabilities, a 50 percent rating for PTSD and individual 10 percent ratings for a right knee disability and left upper extremity account for the compensable service-connected disabilities since 1992. Based on the effective dates assigned for the left upper extremity and right knee, the veteran's combined rating of 60 percent has been in effect since 1992. The record reflects that the medical treatment the veteran has received in the time pertinent to this appeal has been directed more recently to the left upper extremity and PTSD. Upon review of the record, the Board finds that there is substantial evidence supporting a total rating for compensation purposes based on IU. The Board has noted that the veteran has several compensable service-connected disabilities and that a psychiatric disorder that is service-connected has been reported significantly disabling. The SSA apparently has viewed the PTSD as appreciably significant in preventing gainful employment. The record as it now stands would lead one to conclude reasonably that the orthopedic and neurologic disorders are not as prominent at this time. He has not worked for any significant period since 1988 and it does not appear that he is a viable candidate for gainful employment in view of his multiple system disabilities. The Board does not overlook the opinions on recent VA examinations directed to the veteran's employability. The SSA record that includes probative evidence of the level of psychiatric impairment conflicts with the VA assessment. However the Board observes that VA outpatient record corresponding to the 1998 SSA review show a decrease in the GAF assigned from previous VA examinations. The psychiatric disability predominates. The most recent examination of record in 1998 focused on PTSD. Viewed objectively, the record, in particular the course of the principal service connected psychiatric disability as reflected in VA and SSA reports does appear to provide a plausible basis for a favorable decision on this matter. Significantly, the veteran was apparently not scheduled for a VA psychiatric examination in 1998 after contemporaneous VA outpatient and SSA records showed deterioration in his disability. The Board does not find of record evidence of such probative weight against the claim so as to place the preponderance of the evidence against the claim. There is none that indicates that but for a nonservice-connected disability, the veteran would have been capable of working at any time recently, the service-connected disabilities notwithstanding. Although the RO continued to deny IU entitlement in 1999, the SSA decision and pertinent examinations viewed collectively did not appear to offer evidence that would, when viewed collectively, preponderate against the claim for IU benefits. The SSA decision no doubt considered the veteran's education and work background and also found his complaints credible. The SSA examiner in 1998 concluded in essence that PTSD resulted in significantly disabling limitations on any type of employment that the veteran could perform. The impact of the veteran's right knee and left upper extremity cannot be ignored, although PTSD appears to be in the forefront of appreciably disabling disabilities. Accordingly, the Board finds that the evidentiary record supports a total rating for compensation purposes based on IU. Vettese, 7 Vet. App. at 35. ORDER An increased evaluation for shell fragment wound scar, left lateral chest area is denied. An increased evaluation for shell fragment wound scar, left posterior chest area is denied. Entitlement to a total disability rating based on IU is granted, subject to the regulations governing the payment of monetary awards. Mark J. Swiatek Acting Member, Board of Veterans' Appeals