Citation Nr: 0002171 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 94 23 406 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an increased evaluation for service- connected post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 2. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran and his spouse ATTORNEY FOR THE BOARD T.J. Kniffen, Associate Counsel INTRODUCTION The veteran had active service from June 1943 until September 1945. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 1993 rating decision from the Los Angeles, California Department of Veterans Affairs (VA) Regional Office (RO) that denied entitlement to a rating in excess of 10 percent for PTSD and service connection for bilateral hearing loss. The RO in a March 1995 decision assigned a rating of 30 percent for the veteran's PTSD. In AB v. Brown, 6 Vet. App. 35 (1993), the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") held that on a claim for an original or increased rating, the veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. The Board notes that the RO denied entitlement to service connection for solar burns in both eyes in the March 1995 decision. The veteran did not submit a notice of disagreement regarding this determination. As the veteran has not filed a notice of disagreement with that decision, this matter is not presently before the Board. See 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302 (1999). During his personal hearings the, veteran described a buzzing noise in both ears. His representative asserted he suffers from tinnitus, the implication being he incurred this asserted disability in service. Since the RO did not address this contention, the Board refers the issue of service connection for tinnitus to the RO. FINDINGS OF FACT 1. The veteran's service-connected PTSD is moderate in degree and is manifested by anxiety, depression, insomnia and anger as well as some difficulty in establishing effective work and social relationships. 2. There is no competent medical evidence of record demonstrating a nexus between the veteran's current hearing loss disability and his service. CONCLUSIONS OF LAW 1. The schedular criteria for a 50 percent evaluation for PTSD have been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). 2. The veteran has not submitted evidence of a well-grounded claim of entitlement to service connection for bilateral hearing loss. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran seeks an increased disability rating for PTSD and service connection for bilateral hearing loss. In the interest of clarity the Board will discuss the two issues separately. 1. Entitlement to an increased evaluation for service- connected PTSD, currently evaluated as 30 percent disabling. Factual background In a December 1945 RO decision the veteran was granted service connection for psychoneurosis and a 50 percent disability rating was assigned. In March 1947 and September 1960 rating decisions, 30 and 10 percent disability ratings were assigned, respectively. 1993 and 1994 VA clinical notes reflect the veteran's complaints of insomnia and worrying about the "war" as well as anger and frustration. During an October 1994 hearing, the veteran stated he was attending group therapy and was seeking treatment from a therapist. The veteran and his spouse further stated he experienced nightmares with physical manifestations that require his spouse and he to sleep in different beds. The veteran testified during a May 1995 hearing regarding what he described as racially motivated altercations with shipmates and continued insomnia. In November 1994 the veteran presented for a VA psychiatric examination. The examiner noted the veteran's reports of two stressors, racially motivated altercations with shipmates and combat related injuries and deaths. The veteran reported nightmares that caused him to move involuntarily while sleeping, causing his wife to sleep in a different bed. The veteran complained of depression and quitting employment in 1991 because he could not deal with pressures and depression. The veteran described his only social contact as being with his wife. The veteran appeared moderately to severely depressed with occasional suicidal ideation, but the examiner noted no signs of psychosis or significant cognitive impairment. The examiner diagnosed the veteran with PTSD. In November 1997 the veteran presented for a VA Social and Industrial Survey (SIS). The veteran reported his social system only consisted of his family. The veteran also stated he experienced anger regarding racial relations. The veteran appeared anxious during the interview, complained of chronic insomnia and admitted suicidal ideation. The veteran appeared irritable and tense. The reviewer noted difficulty relating all of the veteran's difficulties with social and industrial functioning to PTSD because of other health problems he experienced. The reviewer rated the veteran with moderate industrial and social impairment of functioning. The veteran presented for a VA mental disorders examination in November 1997. The veteran described his sleeping difficulties that require his wife to sleep in a separate bed. The veteran further reported becoming easily angered, occasionally depressed and experiencing suicidal ideations. He reported consistent employment until a 1993 myocardial infarction and 1996 stroke. Upon examination the veteran appeared alert, oriented times four and cooperative. The veteran cried when discussing his World War II experiences. The examiner diagnosed the veteran with chronic moderate PTSD, with some diminishment in his capacity to work, function socially and clinical depression. In April 1999 the veteran presented for a VA general psychiatric examination regarding anxiety reaction with PTSD. The veteran complained of being paranoid. He stated that every morning he checks under his automobile for bombs. The veteran started crying during the examination and complained of chronic insomnia. He stated he was able to drive and build models as a hobby but did not relate to people. The veteran was diagnosed with anxiety reaction with PTSD and assigned a current GAF of 55 . The examiner stated the veteran's symptoms interfered only moderately with his occupational functioning and social functioning. Applicable law and regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Ratings Schedule). 38 C.F.R. § Part 4 (1998). Separate diagnostic codes identify the various disabilities. The VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The requirements set forth in these regulations for evaluation of the complete medical history of the veteran's condition operate to protect veterans against adverse decisions based on a single, incomplete or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet. App. at 593-94. 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. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1998). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1998). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. §§ 4.1, 4.2 (1999); See also Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes that effective November 7, 1996, during the pendency of this appeal, the VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating mental disorders including PTSD. 61 Fed. Reg. 52695 (Oct. 8, 1996) (codified at 38 C.F.R. § 4.130). Because the veteran's claim was filed before the regulatory change occurred, he is entitled to application of the version most favorable to him. See Karnas, 1 Vet. App. at 311. In the instant case, the RO provided the veteran notice of the old and new regulations in the May 1999 supplemental statement of the case. Thus, the Board finds that it may proceed with a decision on the merits of the veteran's claim, with consideration of the original and revised regulations, without prejudice to the veteran. See Bernard v Brown, 4 Vet. App. 384, 393-394(1993). Before November 7, 1996, the VA Schedule read as follows: General Rating Formula for Psychoneurotic Disorders: 100% The attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic, symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Demonstrably unable to obtain or retain employment. 70% Ability to establish and maintain effective or favorable relationships with people is severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. 50% Ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. 30% Definite impairment in the ability to establish or maintain effective and wholesome relationships with people, with psychoneurotic symptoms resulting in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). On and after November 7, 1996, the VA Schedule read as follows: 100% Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. 70% Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence) spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 50% 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 (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. 30% Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). Words such as "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. 4.6 (1998). It should also be noted that use of terminology such as "moderate" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104 (West 1991); 38 C.F.R. §§ 4.2, 4.6 (1999). Analysis The veteran is currently rated as 30 percent disabled for his service-connected PTSD. He contends that his disability has worsened in severity to such a degree that it is no longer compensated by his presently assigned disability rating. Preliminary matters - well groundedness of the claim; duty to assist; standard of proof Initially, the Board concludes that the veteran's claim is well grounded within the meaning of the statutes and judicial construction. See 38 U.S.C.A. § 5107(a) (West 1991). When a veteran claims that he has suffered an increase in disability, or that the symptoms of his disability are more severe than is contemplated by the currently assigned rating, that claim is generally considered well grounded. Bruce v. West, 11 Vet. App. 405, 409 (1998); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). Upon the submission of a well-grounded claim, the VA has a duty to assist the veteran in developing the facts pertinent to his claim. 38 U.S.C.A. § 5107. In the instant case, there is ample medical and other evidence of record, the veteran has been provided with a recent VA examination and two personal hearings, and there is no indication that there are additional records that have not been obtained and which would be pertinent to the present claim. Thus, no further development is required in order to comply with VA's duty to assist as mandated by 38 U.S.C.A. § 5107(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Veterans Appeals stated that "a veteran need only demonstrate that there is an "approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. As noted above, the Board will consider the veteran's claim under both the current and the former schedular criteria in accordance with the Court's ruling in Karnas, 1 Vet. App. at 311. Discussion With respect to the current criteria, the Board finds that the evidence of record shows that the current severity of the veteran's PTSD more nearly approximates a rating of 50 percent. 38 C.F.R. § 4.7 (1999). The Board recognizes that there is evidence of record which does not support a rating of 50 percent under the new criteria of Diagnostic Code 9411. There is no evidence which suggests that the veteran suffers from circumstantial or stereotyped speech. There is also no evidence that he experiences impaired judgment or difficulty understanding complex commands. However, the Board finds that the weight of the evidence supports a 50 percent disability rating for PTSD under the current regulations. The Board notes that during the November 1997 SIS the veteran reported that his social system and contacts consisted only of his family. The reviewer rated the veteran with moderate industrial and social impairment, but indicated health problems other than PTSD impacted this rating. During the November 1997 VA mental disorders examination the veteran cried when discussing World War II and reported becoming easily angered, occasionally depressed and experiencing suicidal ideations, reflecting disturbances of motivation and mood, part of the criteria set forth in the current regulations for a 50 percent disability rating. The Board notes that during the April 1999 VA psychiatric examination, the veteran told the examiner he was paranoid and that although he could drive an automobile, he did not relate to people. The Board notes that the examiner assigned a GAF of 55, which reflects moderate symptoms or moderate difficulty in social, occupational or school functioning, for example few friends and flat affect. Flat affect, panic attacks more frequently than once per week and moderate occupational and social impairment were noted or diagnosed during the April 1999 VA examination and are part of the current criteria that allows a 50 percent rating for PTSD. Therefore, while the veteran may have not demonstrated all of the criteria for a 50 percent disability rating under Diagnostic Code 9411, the Board finds that the aforementioned evidence demonstrates a degree of occupational and social impairment which "more nearly approximates" the criteria for a 50 percent rating rather than a 30 percent rating. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 9411 (1999). The Board finds the manifestations of the veteran's disability which support a 50 percent disability rating to be more significant and have a greater impact on the veteran's ability to function than those which do not meet the criteria for a 50 percent evaluation. The Board has considered whether an evaluation of 70 percent or higher under the new criteria might be warranted. However, the evidence of record does not demonstrate that the veteran's PTSD is manifested by deficiencies in most areas such as work, school and family relations, nor does the veteran experience near-continuous panic or depression, spatial disorientation or neglect of personal appearance. 38 C.F.R. § 4.130, Diagnostic Code 9440 (1999). Although the veteran's service-connected PTSD may have some impact on his employability, he had been able to hold a steady job until his 1993 myocardial infarction and 1996 stroke and there is no objective evidence that his psychiatric disability since that time would cause significant additional interference with employment. Very significantly in the Board's judgment, the April 1999 VA examiner specifically assigned a GAF score of 55, which is indicative of only moderate psychiatric symptomatology, and the SIS specifically referred to the veteran's physical problems as impacting on this social and industrial adaptability. Thus, the Board finds that the preponderance of the evidence of record is against assignment of a 70 percent disability evaluation under the new criteria. In accordance with the Court's ruling in Karnas, the Board has also considered whether a 70 percent or higher evaluation is warranted for the veteran's PTSD under the old criteria. However, the Board believes that the evidence of record has not demonstrated that the veteran's PTSD is manifested by severe impairment of ability to establish and maintain effective or favorable relationships with people or obtain or retain employment. As discussed above, the veteran's marriage and family are intact and he stopped working because of physical, nor psychiatric, problems. Thus, the Board finds that the preponderance of the evidence is against a rating in excess of 50 percent under the old criteria. The evidence of record, which has been discussed in detail above, is consistent in describing the veteran's PTSD as "moderate". In summary, the Board finds that the competent and probative evidence of record supports the assignment of a 50 percent disability rating for the veteran's PTSD under the new criteria. See 38 C.F.R. § 4.7. Furthermore, for the reasons and bases stated above, the Board also finds that the preponderance of the evidence is against assignment of a rating in excess of 50 percent under both the new and old criteria. 2. Entitlement to service connection for bilateral hearing loss. Applicable law and regulations Service connection In general, service connection may be established for disability resulting from disease or injury suffered in the line of duty. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). In cases in which sensorineural hearing loss is involved, service connection may be granted if permanent hearing loss appeared to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999); Hensley v. Brown, 5 Vet. App. 155, 158 (1993). Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385 (1999). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Service connection may also be granted for hearing loss, notwithstanding the lack of a diagnosis of hearing loss in service or within one year thereafter, if the evidence demonstrates that there is a connection between military service and the current disability. 38 C.F.R. § 3.303(d) (1999); Cosman v. Principi, 3 Vet. App. 505, 505 (1992); Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). Well grounded claims The threshold question with regard to the veteran's claim for service connection is whether the claim is well grounded pursuant to 38 U.S.C.A. § 5107(a). In order for a claim to be well grounded, there must be competent evidence of (1) a current disability (a medical diagnosis); (2) incurrence or aggravation of a disease or injury in service (lay or medical evidence); (3) a nexus between the in- service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). Where the determinative issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Lay assertions of medical causation cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a). Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Combat status The Board further notes that 38 U.S.C.A. § 1154(b) (West 1991) provides that, with respect to combat veterans, "The Secretary shall accept as sufficient proof of service- connection . . . satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions and hardships of such service . . . Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary." See also 38 C.F.R. § 3.304(d) (1999). The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") rendered a decision that further clarified the law and VA regulations pertaining to the use of lay statements in cases involving combat veterans. Caluza v. Brown, 7 Vet. App. 498 (1995). The Court in Caluza emphasized that 38 U.S.C.A. § 1154(b) "relaxes the evidentiary requirements for adjudication of certain combat- related VA-disability-compensation claims" by allowing lay or other evidence to prove incurrence of a condition by combat. 7 Vet. App. at 507. Accordingly, the " 'lay or other evidence' [will] be accepted as sufficient proof of service incurrence or aggravation unless there is 'clear and convincing evidence' that the disease or injury was not incurred or aggravated in service . . . . [citing Jensen v. Brown, 19 F.3d 1413, 1717 (Fed. Cir. 1994)]." 7 Vet. App. at 508. However, 38 U.S.C.A. § 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to the current disorder. Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996) (absence of competent medical evidence linking a claimed disorder to service rendered claim not well grounded). Section 1154(b) does not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. A veteran must still generally establish that his claim is well grounded by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. Gregory v. Brown, 8 Vet. App. 563, 567 (1996). Factual background The veteran served aboard an aircraft carrier in the Pacific during World War II. His service medical records reflect that upon entry into service in 1943 and discharge in 1946 no hearing abnormalities were noted. A 1947 VA examination reflects no abnormalities regarding the veteran's hearing. In October 1992 the veteran filed his initial claim for entitlement to service connection for hearing loss. VA clinical notations for 1992 and 1993 indicate the veteran's complaints of hearing loss and tinnitus. Specifically, the veteran reported in December 1992 that he could not hear in his left ear because of an explosion during service. He reported constant ringing in his ears. In December 1992 the veteran was diagnosed with mild to moderate high frequency hearing loss and mild low frequency hearing loss. In May 1993 he was diagnosed with high frequency hearing loss with virtually no speech discrimination and constant tinnitus. During October 1994 and May 1995 hearings the veteran described a buzzing noise in both ears which he said probably started during his military service that involved working near eight inch guns on an aircraft carrier. In April 1999 the veteran presented for a VA hearing loss examination. The veteran's reported history indicated left ear hearing impairment since 1960 with constant left sided tinnitus since approximately 1979 and intermittent tinnitus in his right ear. The veteran reported that in 1943 he was an aircraft landing signal officer on an aircraft carrier where he was exposed to the sounds of aircraft engines. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 20 25 40 65 LEFT 65 65 80 90 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 28 percent in the left ear. The veteran was diagnosed with asymmetric sensorineural hearing loss. Constant tinnitus left ear and intermittent tinnitus right ear. The examiner indicated the veteran's right ear hearing loss was less than expected for an individual the veteran's age. The examiner stated that in the absence of a 4000Hz notch there was no evidence to implicate excessive military noise exposure as a cause of the veteran's hearing loss. Regarding the veteran's left ear with tinnitus, the examiner stated the loss does not appear characteristic of excessive noise exposure. The examiner concluded by stating that if the veteran underwent magnetic resonance imaging (MRI) and computed tomography (CT) testing that showed retrocochlear lesion, this result would not be military related. Analysis As stated above, in order for a claim to be well grounded, there must be competent evidence of (1) a current disability (a medical diagnosis); (2) incurrence or aggravation of a disease or injury in service (lay or medical evidence); (3) a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). The first prong of the Caluza test is satisfied in that the current medical evidence establishes that a hearing disability presently exists. In each ear, the auditory threshold is 40 decibels or greater in at least one of the specified frequencies, and the veteran's speech recognition scores are both less than 94 percent. 38 C.F.R. § 3.385. The Board finds that the second prong of the Caluza test has also been met because of the veteran's statements that he incurred his hearing disability in service while working in the vicinity of eight inch guns and aircraft during World War II. However, as to the third prong of the Caluza test, there is no medial nexus evidence of record which would serve to link the veteran's current hearing loss and his World War II service. The veteran alleges that his current bilateral hearing loss is the result of exposure to acoustic trauma associated with aircraft and other battle noises. The Board has no reason to dispute the veteran's statements that he was exposed to combat. The provisions of § 1154(b) do not, however eliminate the requirement that there be evidence of a nexus between a current disability and active service. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996); Gregory v. Brown, 8 Vet. App. 563, 567 (1996). The veteran has not presented any evidence showing that his current bilateral hearing loss is related to service. While the VA examiner notes exposure to aircraft engines during service in the history as reported by the veteran, that examiner does not relate the hearing loss diagnosis to exposure to military related noise. In the current record, no other competent medical professional has related the hearing loss disability to noise exposure or any incident of service. Although the veteran alleges a connection between service and his current hearing loss, competent medical evidence is necessary to establish the third prong of the Caluza test. Lay persons are not considered competent to offer medical opinions regarding causation or diagnosis. Grottveit v. Brown, 5 Vet. App 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Accordingly, because the veteran has not presented a well-grounded claim of entitlement to service connection, the benefit sought on appeal is denied. Additional Comments When a claim is not well grounded, the VA does not have a duty to assist the veteran in the development of facts pertaining to his claim. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). However, the VA may be obligated to advise the veteran of the evidence needed to complete the application. This obligation depends upon the particular facts of the case and the extent to which the VA has previously advised the veteran of the evidence needed to be submitted with a VA benefits claim. Robinette v. Brown, 8 Vet. App. 69 (1995). The Board is not on notice of the existence of any other possible evidence that exists that, if true, would make the veteran's claim of entitlement to service connection for bilateral hearing loss plausible. This decision serves to inform the veteran of the kind of evidence that would be needed to make his claim well grounded. By this decision, the Board informs the veteran that in order to make his claim for entitlement to service connection well grounded, he will need to submit competent medical evidence establishing a nexus between service and his current hearing loss disability. As noted in the Introduction, the issue of entitlement to service connection for tinnitus is being referred to the RO. The Board intimates no conclusion with respect to the ultimate outcome of that issue. ORDER An increased rating of 50 percent is granted for the veteran's PTSD, subject to controlling regulations applicable to the payment of monetary benefits. A well-grounded claim not having been presented, the veteran's claim of entitlement to service connection for bilateral hearing loss is denied. Barry F. Bohan Member, Board of Veterans' Appeals See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995): GAF is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p.32.] GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). The United States Court of Appeals for Veterans Claims (Court) has stated the word "definite", as used in the old schedular criteria for a 30 percent evaluation, is a qualitative term rather than a quantitative term. Hood v. Brown, 4 Vet. App. 301, 303 (1993). However, the degree of impairment, which would lead to an award at the 30 percent level, can be quantified. Cox v. Brown, 6 Vet. App. 459, 461 (1994). In a precedent opinion, dated November 9, 1993, the VA General Counsel concluded that "definite" is to be construed as "distinct, unambiguous, and moderately large in degree." "Definite" represents a degree of social and industrial inadaptability that is "more than moderate but less than rather large." O.G.C. Prec. 9-93 (Nov. 9, 1993). VA, including the Board, is bound by this interpretation of the term "definite." 38 U.S.C.A. § 7104(c) (West 1991); 38 C.F.R. § 3.101 (1998). Denoting the eighth cranial nerve. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1456 (28th ed. 1994)