The veteran appealed a Board decision denying an increased rating for coronary artery disease and a total disability rating based on individual unemployability. The record showed significant cardiac treatment, bypass surgery, and evidence suggesting limitations on physical activity and employment. The Secretary conceded that the existing medical record was not sufficiently developed to support final adjudication and that additional clinical information could clarify whether the veteran had chronic residuals of congestive heart failure or angina.

The Court accepted the concession and held that remand was required. Citing 38 C.F.R. § 4.2 and the duty to assist under 38 U.S.C. § 5107(a), the Court explained that an inadequate examination report cannot support a rating decision. It also noted that VA may obtain additional medical opinions or remand for a full examination when clarification is needed. The Court further directed that, on remand, the Board must provide adequate reasons or bases and address both the unemployability and increased-rating issues after completing proper development.

The case matters because it reinforces that VA cannot deny a rating or TDIU claim on an underdeveloped medical record. Where severity or employability turns on missing medical detail, the remedy is additional development and a fully informed examination before adjudication.

If the medical evidence of record is insufficient for rating purposes, VA must obtain additional development or a thorough examination before adjudicating the claim.

Use this case to challenge denials based on incomplete examinations or missing clinical detail, especially in increased-rating and TDIU appeals.

It is a practical reminder that the duty to assist requires a decision on a complete record, not speculation. The case is especially useful when the Board relies on outdated, vague, or clinically incomplete evidence to deny severity or employability.

Relying on an inadequate VA examination or incomplete medical record.

A veteran is denied an increased heart-disease rating even though the exam does not address current functional limits, residuals, or work impact. Counsel cites this case to seek remand for a new examination and updated clinical findings.

Argue for remand when the examination lacks sufficient detail, fails to address key symptoms or functional impact, or does not permit a fully informed decision on rating or TDIU.

Green v. Derwinski, Wilson v. Derwinski, Littke v. Derwinski, Gilbert v. Derwinski, Ledford v. Derwinski