Citation Nr: 1416572 Decision Date: 04/14/14 Archive Date: 04/24/14 DOCKET NO. 09-24 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to special monthly compensation based on the need for regular aid and attendance or by reason of being housebound, for purposes of accrued benefits. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Paul S. Rubin, Counsel INTRODUCTION The Veteran had active service in the United States Army from November 1943 to December 1945, and his awards and decorations included the Combat Infantryman Badge (CIB). The Veteran died in April 2007, and the appellant is his surviving spouse. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In July 2013, the appellant presented testimony at a travel board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the electronic claims folder. The Board remanded the appeal in October 2013 for further development. The case has since been returned to the Board for appellate review. In the October 2013 Board decision, the Board also adjudicated the issue of whether a claim for service connection for a brain injury was pending at the time of the Veteran's death, for purposes of accrued benefits. This issue was denied by the Board. Thus, it is no longer on appeal. The Board also notes that the service connection for the cause of the Veteran's death has already been granted. This appeal was processed using the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal, with the exception of a duplicate hearing transcript. FINDINGS OF FACT 1. At the time of the Veteran's death in April 2007, there was a pending claim for special monthly compensation based on the need for regular aid and attendance or by reason of being housebound. 2. With regard to housebound benefits, the Veteran did not have a service-connected disability rated as 100 percent disabling. The Veteran's TDIU rating due to a single disability (PTSD) does meet this requirement under VA caselaw, but he did not have additional service-connected disabilities independently ratable at 60 percent or more when combined and did not meet the criteria with regard to being "permanently housebound" due to service-connected disabilities. 3. With regard to aid and attendance benefits, the Veteran was not blind or nearly blind; did not have anatomical loss or loss of use of both feet or one hand and one foot; and was not permanently bedridden, due to service-connected disabilities. Although his nonservice-connected dementia and other disorders required the care or assistance of another person on a regular basis to protect the Veteran from the hazards or dangers incident to his or her daily environment, his service-connected disabilities did not require the regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to special monthly compensation benefits by reason of being permanently housebound, for purposes of accrued benefits. 38 U.S.C.A. §§ 1114(s), 5103, 5103A, 5107, 5121 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.350(i), 3.1000 (2013). 2. The criteria are not met for entitlement to special monthly compensation benefits by reason of being in need of aid and attendance of another person, for purposes of accrued benefits. 38 U.S.C.A. §§ 1114(l), 5103, 5103A, 5107, 5121 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.350(b), 3.352(a), 3.1000 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In this regard, the RO sent the appellant VCAA notice letters dated in July 2007 and November 2013. These letters provided guidance in accordance with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) by: (1) informing her about the information and evidence not of record that was necessary to substantiate her accrued benefits claim for special monthly compensation; (2) informing her about the information and evidence the VA would seek to provide; and (3) informing her about the information and evidence she was expected to provide. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The November 2013 VCAA letter sent from the RO also advised the appellant a disability rating and an effective date for the award of benefits will be assigned if accrued benefits are awarded, as required by Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). The Board has also considered the duty to assist, as required by the VCAA. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013). Regarding the duty to assist in the specific context of accrued benefits, such claims are decided based on the evidence of record at the time of the Veteran's death. 38 C.F.R. § 3.1000(d)(4). Thus, this matter involves an inquiry based upon the evidence of record prior to the Veteran's death and not based upon the development of new evidence. During the Veteran's lifetime, private and VA treatment records were secured and submitted. The appellant and her representative have submitted additional private medical evidence and a TVC Form 16, Statement of Attending Physician, received by the RO in February 2007. The appellant has also submitted an April 2007 death certificate and provided July 2013 hearing testimony. The appellant has not identified any evidence not already associated with the file that should have been in VA's constructive possession. The Board does note that the majority of the Veteran's service treatment records are missing and presumed destroyed in a fire in July 1973. See negative responses from the National Personnel Records Center (NPRC) dated in September 2002, November 2003, September 2007, and November 2007. Only certain morning and sick reports were secured. In cases where service treatment records are missing or presumed destroyed, in addition to the Board's heightened duty to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule, the Board also has a heightened duty to assist the claimant with the development of evidence in support of her claim. See Daye v. Nicholson, 20 Vet. App. 512, 515 (2006); Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005); Washington v. Nicholson, 19 Vet. App. 362, 369 (2005); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Regardless, as explained below, the decision herein is based on consideration of whether the Veteran is entitled to special monthly compensation based on his medical condition in 2006 and 2007, in the months preceding his death in April 2007. It does not involve consideration of any outstanding service treatment records dated in 1945. Consequently, the fact that the majority of service treatment records are missing is not relevant to the issue of whether the Veteran was entitled to special monthly compensation based on the need for regular aid and attendance or by reason of being housebound, for purposes of accrued benefits. In addition, the appellant testified at a hearing before the undersigned Veterans Law Judge in July 2013. The undersigned Veterans Law Judge set forth the issues to be discussed, clarified the appellant's contentions, and elicited further information as when appropriate. The hearing focused on the elements necessary to substantiate the claim and the appellant, through her testimony and questioning by her representative, demonstrated her actual knowledge of the elements necessary to substantiate her special monthly compensation claim. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). Finally, with regard to the previous October 2013 Board remand, the Board finds that the RO/AMC substantially complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial compliance would be required, not strict compliance). Specifically, pursuant to the remands, the AMC provided additional corrective VCAA notice for special monthly compensation to the appellant and issued a supplemental statement of the case (SSOC) that included the provisions of 38 C.F.R. § 3.352 for aid and attendance. As such, the AMC has substantially complied with the Board's instructions. Thus, the Board finds that no further action is necessary under the statutory and regulatory duties to notify and assist. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013). II. Factual Background and Contentions The Veteran died in April 2007 at a private nursing home. The death certificate lists the immediate cause of death as organic brain syndrome, multiple cerebrovascular ischemic attacks, chronic obstructive pulmonary disease (COPD), and coronary artery disease. With regard to organic brain syndrome, VA and private treatment records in the years prior to his death document that the Veteran's health condition deteriorated due to Alzheimer's disease and dementia. These conditions are all nonservice-connected disabilities. The death certificate also lists service-connected partial complex seizures as a significant condition contributing to, but not resulting in the underlying cause of death. No autopsy was performed. At the time of his death in April 2007, service connection was established for the following disabilities: bilateral hearing loss, rated as 30 percent disabling; posttraumatic stress disorder (PTSD), rated as 30 percent disabling; and bilateral tinnitus, rated as 10 percent disabling. The combined service-connected disability rating was 60 percent. See 38 C.F.R. § 4.25 (combined ratings table). The Veteran also was in receipt of a total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU) since June 25, 2003. The appellant filed an Application for Death and Indemnity Compensation (DIC) and Accrued Benefits (VA Form 21-534) in May 2007. Thereafter, in a June 2009 rating decision, the RO granted service connection for the cause of the Veteran's death. In particular, the RO cited the opinion of a May 2009 VA neurological examiner, who opined that the Veteran's seizure disorder should be service-connected as a contributory cause of death, as it stemmed from a 1945 in-service combat injury to the head, circumstantially confirmed by service department morning and sick reports. The appellant has claimed that the Veteran sustained a traumatic brain injury during combat service in 1945 when an anti-tank gun exploded above his head, thereby rendering him unconscious with a concussion and hospitalized for several weeks. She has stated that his condition progressively worsened over the years until his brain function declined and he went into a persistent vegetative state. She has maintained that she should be awarded accrued benefits for special monthly compensation on the basis that the Veteran's in-service brain injury caused the development of his organic brain syndrome, Alzheimer's disease, and dementia, and aggravated his service-connected PTSD symptoms. She has also asserted that the symptoms of the Veteran's service-connected seizure disorder and PTSD are difficult to distinguish from his dementia symptoms. As a result of his service-connected symptoms, she maintains the Veteran was entitled to special monthly compensation aid and attendance and/or housebound benefits in the months prior to his death, as he required the regular assistance of others to take care of his basic needs as his condition slowly deteriorated. See July 2013 hearing testimony at pages 1-11; September 2007 NOD; August 2007, December 2007, June 2009, and February 2014 appellant statements. III. Law and Analysis Accrued benefits are defined as periodic monetary benefits authorized under law administered by VA, to which a payee was entitled at his or her death under existing ratings or decisions or those based on evidence in the file at the date of death, and due and unpaid. 38 U.S.C.A. § 5121(a) (West 2002 & Supp. 2013); 38 C.F.R. 3.1000(a) (2013); Ralston v. West, 13 Vet. App. 108, 113 (1999). Applications for accrued benefits must be filed within one year after the date of death. 38 U.S.C.A. § 5121(c); 38 C.F.R. § 3.1000(c). As noted, accrued benefits may only be awarded on the basis of the evidence in the file at the Veteran's date of death. 38 C.F.R. § 3.1000(a). "Evidence in the file at date of death" means evidence in VA's possession on or before the date of the beneficiary's death, even if such evidence was not physically located in the VA claims folder on or before the date of death, in support of a claim for VA benefits pending on the date of death. 38 C.F.R. § 3.1000(d)(4); Hayes v. Brown, 4 Vet. App. 353 (1993). A "claim for VA benefits pending on the date of death" means a claim filed with VA that had not been "finally adjudicated" by VA on or before the date of death. Such a claim includes a deceased beneficiary's claim to reopen a finally disallowed claim based upon new and material evidence or a deceased beneficiary's claim of clear and unmistakable error in a prior rating or decision. Any new and material evidence must have been in VA's possession on or before the date of the beneficiary's death. 38 C.F.R. § 3.1000(d)(5). The term "finally adjudicated claim" means an application, formal or informal, which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is earlier. 38 C.F.R. § 3.160(d); see also 38 C.F.R. §§ 20.1103, 20.1104. Although a Veteran's claim terminates with that Veteran's death, a qualified survivor may carry on, to a limited extent, the deceased Veteran's claim by submitting a timely claim for accrued benefits. See 38 U.S.C.A. § 5121; Landicho v. Brown, 7 Vet. App. 42, 47 (1994). Thus, while the claim for accrued benefits filed by a spouse is separate from the claim filed by the Veteran prior to his death, the accrued benefits claim is derivative of the Veteran's claim and his spouse takes the Veteran's claim as it stood on the date of his death. Zevalkink v. Brown, 102 F.3d 1236, 1242 (Fed. Cir. 1996). In short, for an appellant to prevail on an accrued benefits claim, the record must show that (i) the appellant has standing to file a claim for accrued benefits, (ii) the Veteran had a claim pending at the time of death, (iii) the Veteran would have prevailed on the claim if he had not died; and (iv) the claim for accrued benefits was filed within one year of the Veteran's death. 38 U.S.C.A. §§ 5121, 5101(a); 38 C.F.R. § 3.1000; Jones v. West, 136 F.3d 1299 (Fed. Cir. 1998). At the outset, the Board will consider whether there was a claim for special monthly compensation pending at the time of the Veteran's death in April 2007. In this regard, in February 2007, the Veteran's representative filed a TVC Form 16, Statement of Attending Physician, which found that the Veteran was housebound and in need of aid and attendance for severe dementia, COPD, and coronary artery disease. The RO considered this form to be a claim for entitlement to special monthly compensation. Several months later, the Veteran died in April 2007, before the special monthly compensation claim could be formally adjudicated by the RO. Thus, it is clear the Veteran had a claim for special monthly compensation pending that had not been finally adjudicated by VA on or before the date of death. 38 C.F.R. § 3.1000(d)(5); Jones, 136 F.3d at 1299. See also 38 C.F.R. §§ 3.1(p), 3.155(a). Applications for accrued benefits must be filed within one year after the date of death. 38 U.S.C.A. § 5121(c); 38 C.F.R. § 3.1000(c). A claim for death pension, compensation, or dependency and indemnity compensation (DIC) by a surviving spouse is deemed to include a claim for any accrued benefits. Id. See also 38 C.F.R. § 3.152(b). In the present case, the appellant filed her accrued benefits and DIC claim in a timely manner in May 2007, well within one-year of the Veteran's death. The RO denied the special monthly compensation claim for purposes of accrued benefits in the August 2007 rating decision on appeal. The appellant has appealed this issue to the Board. Upon review of the evidence, the Board finds that the criteria are not met for special monthly compensation based on the need for regular aid and attendance or by reason of being housebound, for purposes of accrued benefits. The appellant is seeking special monthly compensation benefits for the Veteran based on being housebound as set forth under 38 U.S.C.A. § 1114(s) or based on the need for regular aid and attendance at the higher rate as set forth under 38 U.S.C.A. § 1114(l). A veteran or appellant may receive special monthly compensation either by reason of being housebound or based on the need for regular aid and attendance, but may not receive both simultaneously. That is, regular aid and attendance is the greater monetary award. Compare 38 U.S.C.A. § 1114(l) with 38 U.S.C.A. §1114(s). The Board will initially address the issue of whether the Veteran was entitled to the lesser benefit of special monthly compensation by reason of being housebound. Special monthly compensation benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is "permanently housebound" by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i)(1). Subsection 1114(s) for housebound benefits requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under VA law, subsection 1114(s) housebound benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. See Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011). However, in Bradley v. Peake, 22 Vet. App. 280, 293 (2008), the Court held that a total disability rating based on individual unemployability (TDIU) satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more, for purposes of entitlement to special monthly compensation for a housebound rating. In other words, 38 U.S.C. § 1114(s) for housebound benefits does not limit "a service-connected disability rated as total" to only a schedular rating of 100 percent. Id. A TDIU rating based on a single disability is permitted to satisfy the statutory requirement of a total rating. Id. Nonetheless, the TDIU rating based on a single disability that satisfies the total (100 percent) rating requirement must be separate and distinct from the additional disability or disabilities independently ratable at 60 percent or more for purposes of housebound benefits. Id. In addition, the Bradley decision also stated that the decision to treat multiple disabilities as one under 38 C.F.R. § 4.16(a) was specifically limited to TDIU ratings. That is, a TDIU rating based on multiple service-connected disabilities does not satisfy the criteria for one total disability in considering entitlement to housebound benefits under 38 U.S.C.A. § 1114(s). Id. at 290-91. The Court reiterated this interpretation with its holding in Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010) ("The Court today holds that a TDIU rating that is based on multiple disabilities cannot satisfy the section 1114(s) requirements of 'a service-connected disability' because that requirement must be met by a single disability."). However, VA's duty to maximize benefits requires VA to assess all of a claimant's disabilities, regardless of the order in which they were service-connected, to determine whether any combination of disabilities establishes housebound benefits under 38 U.S.C. § 1114(s). Id. A Veteran is "permanently housebound" when he is substantially confined to his house (ward or clinical areas, if institutionalized) or immediate premises as a direct result of his service-connected permanent disability or disabilities, and it is reasonably certain that the disability of disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i)(2). With regard to housebound status, the threshold statutory requirement is that the Veteran must have a single permanent disability rated at 100 percent. In the present case, the Veteran did not have a single service-connected disability rated as 100 percent disabling prior to his death in April 2007. His bilateral hearing loss was rated as 30 percent disabling; his PTSD was rated as 30 percent disabling; and his bilateral tinnitus was rated as 10 percent disabling. Absent a single disability rated as 100 percent disabling, the Veteran normally would not meet the threshold legal criteria for entitlement to special monthly compensation under 38 U.S.C.A. § 1114(s) and 38 C.F.R. § 3.350(i). However, prior to his death, the Veteran was assigned a TDIU rating, effective from June 25, 2003. TDIU was granted by the RO in a November 2004 rating decision. It appears that the RO determined that the effects of the Veteran's service-connected PTSD, alone, were sufficient to award the TDIU rating due to unemployability. Thus, the TDIU award was based on one single disability. The Veteran had reported retiring in 1986 due to his PTSD symptoms. The evidence of record did not reveal that his service-connected hearing loss or tinnitus caused unemployability. Although the PTSD disability was rated as only 30 percent disabling by the RO and was not rated as 100 percent disabling, for special monthly compensation purposes for housebound benefits, the PTSD disability satisfied the requirement of a "service-connected disability rated as total" based on the award of a TDIU rating. See Bradley and Buie, supra. Therefore, this threshold housebound benefits requirement is met. Regardless, as to the statutory housebound criteria, the Veteran did not have additional service-connected disabilities independently ratable at 60 percent or more when combined. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). That is, for his service-connected hearing loss (30 percent) and tinnitus (10 percent), the combined service-connected disability rating was only 40 percent. See 38 C.F.R. § 4.25 (combined ratings table). Therefore, the Veteran did not meet this particular housebound benefits requirement. Moreover, the Veteran does not meet the factual housebound criteria with regard to being "permanently housebound" as the result of his service-connected disabilities. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i)(2). In this regard, the Board acknowledges that VA treatment records, private nursing home records, and private hospice records all reveal that from 2005 to 2007 the Veteran gradually became substantially confined to his home, followed by institutionalization in a nursing home and then hospice care due to permanent disabilities, with reasonably certainty that the disabilities and resultant confinement would continue throughout his lifetime. 38 C.F.R. § 3.350(i)(2). However, with regard to permanent housebound status, the medical evidence of record prior to death does not indicate that his service-connected PTSD, hearing loss, tinnitus, or seizure disorders caused the Veteran to be substantially confined to any premises. Rather, these records, as a whole, reveal that he became "permanently housebound" due to nonservice-connected dementia, COPD, organic brain syndrome, multiple cerebrovascular ischemic attacks, and coronary artery disease. For example, a March 2005 VA treatment record actually noted that the Veteran had not experienced any seizures in three years. He was on seizure medications prior to his death, but with no assessment in the VA, hospice, or nursing home records that he experienced seizures when he was substantially confined to his premises and clinical areas. Moreover, a January 2007 TVC Form 16, Statement of Attending Physician, found that the Veteran was housebound due to severe dementia, COPD, and coronary artery disease. The Veteran had profound memory impairment and was at high risk of getting lost if he left the home. The physician assessed that the dementia was severe and had been present since 2004. Notwithstanding, there was no mention of any of his service-connected disabilities affecting his current status. In addition, VA treatment records beginning in August 2005 first document treatment for Alzheimer's disease with dementia. A January 2007 VA history and physical examination noted a three-year history of memory problems, and a diagnosis was rendered for dementia of three years duration of an unknown etiology. In reviewing the charts, VA medical personnel in January 2007 assessed that the dementia was due to his history of ETOH (drinking alcohol). Private nursing home records dated from February 2007 to April 2007 show treatment and regular care for COPD, dementia, TIAs, and syncope. Private hospice care records dated in April 2007 in the month of his death reveal diagnoses of COPD, hypotension, dementia (with "severe" cognitive defects), and the need for assistance with activities of daily living. The Veteran was confined to his bed for the most part. However, his service-connected disabilities are not shown to have caused any notable symptomatology at that time. VA treatment records dated from December 2006 to February 2007 documented treatment for shoulder pain and dementia due to alcoholism. It was reported that his dementia led to the Veteran getting lost in his neighborhood, dropping cigarettes on the floor (a potential fire hazard), memory loss for the past three years, no eating unless his wife was present, an inability to do chores, no cooking, repeated falls, an inability at times to make it to bathroom, the need for assistance when taking medications, no driving, and a progressively worse condition overall. It was noted the Veteran still managed to drink alcohol with friends daily. Private emergency room records dated in February 2007 showed surgery for a mediastinal cyst, worsening dementia, syncope, and repeated falls. None of these records support the appellant's lay testimony that the Veteran's service-connected PTSD and seizures led to symptomatology resulting in permanent housebound status prior to his death. The Board acknowledges that earlier VA treatment records and Vet Center records dated in 2004, as well as a VA examination dated in August 2003 disclosed treatment for PTSD, with symptoms of short-term memory loss (but no long-term loss), insomnia, nightmares, depression, and anxiety. However, in 2003 and 2004, the Veteran was still able to engage in volunteer work, yardwork, fishing, and gardening. Moreover, no further medical records after 2004 establish that his service-connected PTSD, seizure disorder, hearing loss, or tinnitus in any way led to his eventual housebound status. Rather, the evidence of record clearly documents that his nonservice-connected dementia and Alzheimer's disease caused his gradual deterioration and eventual permanent housebound status. Consequently, the basic requirements for special monthly compensation by reason of being housebound, for purposes of accrued benefits, are not met. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Additionally, special monthly compensation on a higher level under 38 U.S.C.A. § 1114(l) and 38 C.F.R. § 3.350(b) is payable as the result of service-connected disability if the Veteran has an anatomical loss or loss of use of both feet, or of one hand and one foot; has blindness in both eyes with visual acuity of 5/200 or less; is permanently bedridden; or is so helpless as to be in need of regular aid and attendance of another person. "Loss of use of a hand or foot" is defined as no effective function remaining other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. §§ 3.350(a)(2)(i), 4.63. Examples under 38 C.F.R. § 3.350(a)(2) and 38 C.F.R. 4.63 which constitute loss of use of a foot include extremely unfavorable ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 3 1/2 inches or more, or complete paralysis of the external popliteal nerve and consequent foot drop. The following will be accorded consideration in determining the need for regular aid and attendance of another person: Inability of a claimant to dress or undress him or herself, or to keep him or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed him or herself through loss of coordination of the upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). "Bedridden," i.e., the Veteran is actually required to remain in bed, will be a proper basis for the determination. The fact that a Veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. Id. It is not required that all of the disabling conditions enumerated be found to exist before a favorable rating may be made. See generally Turco v. Brown, 9 Vet. App. 222, 224 (1996) (eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met, but not all). The particular personal functions that the Veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the Veteran is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the Veteran's condition is such as would require him or her to be in bed. They must be based on the actual requirements of personal assistance from others. 38 C.F.R. § 3.352(a). The performance of the necessary aid and attendance service by a relative of the beneficiary or other member of his or her household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352(c). Initially, a single disability rated as 100 percent disabling under a schedular evaluation is generally a prerequisite for entitlement to special monthly compensation by reason of the need for regular aid and attendance. Any lesser disability would be incompatible with the requirements of 38 CFR 3.352(a). See VA Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section H, Topic 44, Block b. However, as noted above, the Veteran was awarded TDIU that can be based primarily upon his service-connected PTSD disability. As the TDIU award is premised on a single service-connected disability, the TDIU award satisfies the requirement for a single service-connected disability rated at 100 percent. See again Bradley, 22 Vet. App. at 293. Nevertheless, the Board notes that the medical and lay evidence of record does not reveal anatomical loss or loss of use of both feet, or of one hand and one foot; or blindness in both eyes with visual acuity of 5/200 or less; or the Veteran being permanently bedridden as the result of service-connected disabilities. See 38 U.S.C.A. § 1114(l) and 38 C.F.R. § 3.350(b). Although the Veteran was clearly bedridden in the months leading up to his death, the evidence of record does not show that this was due to his service-connected PTSD, seizure disorder, hearing loss, or tinnitus disabilities. With regard to aid and attendance, the Veteran was 86 years old when he died in April 2007. A January 2007 TVC Form 16, Statement of Attending Physician, found that the Veteran was housebound and in need of aid and attendance for severe dementia, COPD, and coronary artery disease, which were all nonservice-connected disorders. The Veteran had profound memory impairment and was at high risk of getting lost if he left the home. The physician indicated that the dementia was severe and had been present since 2004. There was no indication that the Veteran or his doctor reported that service-connected PTSD, seizure, hearing loss, or tinnitus disabilities played any role. Rather, the physician simply listed the nonservice-connected disabilities rendering him housebound and in need of aid and attendance. The Board acknowledges that VA treatment records, private nursing home records, and private hospice records all reveal that from 2005 to 2007 the Veteran gradually became dependent on his wife and professional medical personnel for food, cooking, and attending to the wants of nature. The Veteran's dementia worsened to the point of mental and physical incapacity, which clearly required care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). The appellant's July 2013 hearing testimony on the Veteran's need for aid and attendance is also probative to this fact. The appellant had to stop working in order to care for the Veteran. In this regard, the Veteran did meet many of the factors of aid and attendance. See Turco, 9 Vet. App. 224 (eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met, but not all). It does not appear the Veteran would have been able to take care of himself without the regular assistance of another. This is not in dispute. However, the evidence of record does not show that his eventual incapacity was due to service-connected disabilities. See 38 U.S.C.A. § 1114(l). All of the medical evidence discussed above in detail regarding housebound status, (which will not be listed here again in order to avoid redundancy), also reflects that there was little to no treatment for service-connected disabilities from 2005 to 2007, leading up to the Veteran's physical and mental incapacity. The Veteran's lay assertions and hearing testimony regarding the impact of the Veteran's service-connected PTSD and seizure disabilities is not supported by the probative medical evidence of record. Consequently, the basic requirements for special monthly compensation on the account of regular aid and attendance are not met. 38 U.S.C.A. § 1114(l); 38 C.F.R. §§ 3.350, 3.352. Therefore, the preponderance of the evidence of record is against the claim for entitlement to special monthly compensation based on the need for regular aid and attendance or by reason of being housebound, for purposes of accrued benefits. 38 U.S.C.A. § 5107(b). ORDER Special monthly compensation based on the need for regular aid and attendance or by reason of being housebound, for purposes of accrued benefits, is denied. ____________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs