Citation Nr: 0726808	
Decision Date: 08/28/07    Archive Date: 09/04/07

DOCKET NO.  04-35 023	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Louisville, 
Kentucky


THE ISSUES

1.  Entitlement to service connection for diabetes mellitus 
to include as secondary to service-connected post-traumatic 
stress disorder (PTSD).

2.  Entitlement to service connection for hypertension to 
include as secondary to service-connected PTSD.  


REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

C. Palmer, Associate Counsel



INTRODUCTION

The veteran had active service from June 1971 to August 1975.  

This matter comes before the Board of Veterans' Appeals 
(Board) on appeal from a March 2003 rating decision of the 
Department of Veterans Affairs (VA) Regional Office (RO) in 
Louisville, Kentucky.

In the March 2003 rating decision, the RO denied the 
veteran's claims of service connection for PTSD, diabetes 
mellitus, and hypertension; however, the Board notes that the 
RO later granted service connection for PTSD with secondary 
alcoholism in a September 2004 rating decision.      


FINDINGS OF FACT

1.  The veteran has been notified of the evidence necessary 
to substantiate his claims, and all relevant evidence 
necessary for an equitable disposition of this appeal has 
been obtained. 

2.  The veteran's diabetes mellitus and hypertension have 
been linked to service-connected PTSD with secondary 
alcoholism by competent medical opinion.  


CONCLUSIONS OF LAW

1.  Diabetes was caused by the veteran's service-connected 
PTSD with secondary alcoholism.  38 U.S.C.A. §§ 1110, 1131, 
5103, 5103A, 5107(b) (West 2002 & Supp. 2005); 38 C.F.R. §§ 
3.102, 3.159, 3.303, 3.310 (2006).  

2.  Hypertension was caused by the veteran's service-
connected PTSD with secondary alcoholism.  38 U.S.C.A. §§ 
1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2005); 38 
C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2006).  


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I.	The Veterans Claims Assistance Act of 2000 (VCAA)

The Veterans Claims Assistance Act of 2000 (VCAA) describes 
VA's duty to notify and assist claimants in substantiating a 
claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 
5103A, 5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159 and 3.326(a) (2006).  

Upon receipt of a complete or substantially complete 
application for benefits, VA is required to notify the 
claimant and his or her representative, if any, of any 
information, and any medical or lay evidence, that is 
necessary to substantiate the claim.  38 U.S.C.A. § 5103(a) 
(West 2002); 38 C.F.R. § 3.159(b) (2006); Quartuccio v. 
Principi, 16 Vet. App. 183 (2002).  Proper VCAA notice must 
inform the claimant of any information and evidence not of 
record (1) that is necessary to substantiate the claim; (2) 
that VA will seek to provide; (3) that the claimant is 
expected to provide; and (4) must ask the claimant to provide 
any evidence in his or her possession that pertains to the 
claim in accordance with 38 C.F.R. § 3.159(b)(1).  VCAA 
notice should be provided to a claimant before the initial 
unfavorable agency of original jurisdiction (AOJ) decision on 
a claim.  Pelegrini v. Principi, 18 Vet. App. 112 (2004).  
But see Mayfield v. Nicholson, 19 Vet. App. 103, 128 (2005), 
rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 
(Fed. Cir. Apr. 5, 2006) (when VCAA notice follows the 
initial unfavorable AOJ decision, remand and subsequent RO 
actions may "essentially cure [] the error in the timing of 
notice").  VCAA notice should also apprise the veteran of 
the criteria for assigning disability ratings and for award 
of an effective date.  Dingess/Hartman v. Nicholson, 19 Vet. 
App. 473 (2006).    

In light of the full grant of benefits sought on appeal in 
this decision, no further notification or assistance is 
necessary to develop facts pertinent to these claims.  Thus, 
any notice defects will be addressed by the RO when 
effectuating the award of benefits.  


II.	Legal Criteria

Service connection may be established on a secondary basis 
for a disability that is proximately due to or the result of 
a service-connected disease or injury.  38 C.F.R. § 3.310(a) 
(2006).  Establishing service-connection on a secondary basis 
requires evidence sufficient to show (1) that a current 
disability exists and (2) that the current disability was 
either (a) caused by or (b) aggravated by a service-connected 
disability.  See 38 C.F.R. § 3.310(a) (2006); see also Allen 
v. Brown, 7 Vet. App. 439 (1995) (en banc) reconciling 
Leopoldo v. Brown, 4 Vet. App. 216 (1993) and Tobin v. 
Derwinski, 2 Vet. App. 34 (1991).

Service connection may be granted on a direct basis for 
disability or injury incurred in or aggravated by active 
military service.  38 U.S.C.A. §§ 1110, 1131 (West 2002); 
38 C.F.R. § 3.303(a) (2006).  As a general matter, service 
connection for a disability on the basis of the merits of 
such claim requires (1) the existence of a current 
disability; (2) the existence of the disease or injury in 
service, and; (3) a relationship or nexus between the current 
disability and any injury or disease during service.  Cuevas 
v. Principi, 3 Vet. App. 542 (1992).  

If a condition noted during service is not shown to be 
chronic, then generally a showing of continuity of symptoms 
after service is required for service connection.  38 C.F.R. 
§ 3.303(b) (2006).  Service connection may also be granted 
for any disease diagnosed after discharge, when all the 
evidence, including that pertinent to service, establishes 
that the disease was incurred in service.  38 C.F.R. 
§ 3.303(d) (2006).  Where a veteran served continuously for 
ninety (90) days or more during a period of war, or during 
peacetime service after December 31, 1946, and diabetes and 
hypertension become manifest to a degree of 10 percent or 
more within one year from date of termination of such 
service, such disease shall be presumed to have been incurred 
in service, even though there is no evidence of such disease 
during the period of service.  38 U.S.C.A. §§ 1101, 1112, 
1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2006).  This 
presumption is rebuttable by affirmative evidence to the 
contrary.  Id.    

Where the determinative issue involves a medical diagnosis or 
causation, competent medical evidence is required.  Grottveit 
v. Brown, 5 Vet. App. 91 (1993).  This burden typically 
cannot be met by lay testimony because lay persons are not 
competent to offer medical opinions.  Espiritu v. Derwinski, 
2 Vet. App. 492, 494-95 (1992).  However, lay persons can 
provide an eye-witness account of a veteran's visible 
symptoms.  See, e.g., Caldwell v. Derwinski, 1 Vet. App. 466, 
469 (1991) (competent lay evidence concerning manifestations 
of a disease may form the basis for an award of service 
connection where a claimant develops a chronic disease within 
a presumptive period but has no in-service diagnosis of such 
disease).  

The record reflects that the veteran does not have the 
requisite medical expertise to diagnose his claimed disorders 
or render a competent medical opinion regarding their causes.  
Thus, competent medical evidence showing that his claimed 
disorders are related to service is required.  


III.	Analysis 

The veteran essentially contends that his service-connected 
PTSD aggravated his current hypertension and diabetes and 
seeks service connection for the disorders on a secondary 
basis.  

The Board notes that there is ample medical evidence of 
record showing that the veteran is currently diagnosed with 
hypertension and diabetes.  Indeed, the veteran's VA and 
private treatment records contain numerous clinical findings 
of hypertension and diabetes mellitus.  It is additionally 
noted that the veteran's private physicians, J.O.J., M.D. and 
J.G.D., M.D., reference the veteran's hypertension and 
diabetes in letters dated in September 2004.  Furthermore, 
the VA medical examiner included impressions of type 2 
diabetes and high blood pressure in the June 2004 examination 
report.    

The record also contains a competent medical opinion linking 
the veteran's hypertension and diabetes to his service-
connected PTSD.  Specifically, Dr. J.O.J. wrote in September 
2004 correspondence that the veteran's PTSD aggravates 
control and management of his type 2 diabetes mellitus as 
well as his hypertension.  It is also observed that a 
registered nurse practitioner (J.D., ARNP) wrote in a 
February 2006 letter that it was her medical opinion that the 
veteran's PTSD may have exacerbated his diabetes and his 
diabetes may have exacerbated his vascular disease, thus 
increasing his hypertension.  

The Board further observes there is no competent medical 
opinion unfavorable to the veteran's assertions that his PTSD 
aggravated his diabetes and hypertension apparent in the 
record.  Although the veteran underwent VA examination for 
his PTSD as well as his hypertension and diabetes in June 
2004, neither of the VA examiners offered a medical opinion 
regarding whether the veteran's diabetes and hypertension was 
related to his service-connected PTSD.  The June 2004 
examining VA psychologist wrote that he was unaware of any 
means of establishing a direct line of causality between PTSD 
and the veteran's claimed disorders but would defer to 
medical examiners that are better able to address such 
questions.  The June 2004 VA medical examiner included 
impressions of diabetes type 2 and high blood pressure in the 
examination report but made no comment regarding whether such 
disorders were caused or aggravated by the veteran's PTSD.  
While the January 2007 Supplemental Statement of the Case 
notes that an opinion was being requested from a VA 
psychiatrist regarding the question of whether or not the 
veteran's hypertension and diabetes mellitus, type II were 
aggravated by service-connected PTSD, the record reflects 
that no such request was made.  

Thus, the Board finds that the veteran's assertion that his 
current hypertension and diabetes were aggravated by service-
connected PTSD is supported by the competent medical evidence 
of record.  

The Board, however, notes that the record also contains a 
competent medical opinion that links the veteran's 
hypertension and diabetes mellitus to alcoholism, which is 
also service-connected as secondary to PTSD.  Indeed, Dr. 
J.G.D. wrote in a September 2004 letter that it appeared much 
more likely that both [the veteran's] hypertension and 
diabetes were the result of his chronic alcoholism, its 
attendant difficulties and disabilities.  There is no other 
medical opinion of record regarding the cause of the 
veteran's diabetes and hypertension.      

Thus, the Board finds that there is also competent medical 
evidence showing that the veteran's hypertension and diabetes 
were caused by service-connected alcoholism.  

While the Board recognizes that the veteran and his 
representative have asserted that the veteran's hypertension 
and diabetes were aggravated by PTSD during the course of 
this appeal, the veteran's representative also contended in 
the alternative that the veteran was entitled to service 
connection on a secondary basis as due to his chronic 
alcoholism and cited the aforementioned September 2004 
opinion by Dr. J.G.D. in the June 2007 Appellant's Brief.  As 
previously explained, the veteran's alcoholism has been 
service-connected by VA as a disorder secondary to the 
veteran's PTSD disability and alcoholism has even been 
characterized and adjudicated together with PTSD (i.e., PTSD 
with secondary alcoholism).  Although the medical evidence 
shows that the veteran is entitled to service connection for 
hypertension and diabetes because the disorders were 
aggravated by PTSD as discussed above, the medical evidence 
also shows that the veteran is entitled to service connection 
for diabetes and hypertension because the disorders were 
caused by alcoholism.  

As the veteran is entitled to the greater benefit in this 
case, the Board finds that the medical evidence shows that 
diabetes and hypertension were caused by service-connected 
PTSD with secondary alcoholism and an award of service 
connection for diabetes and hypertension on such basis is 
warranted.  



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ORDER

Entitlement to service connection for diabetes mellitus to 
include as secondary to service-connected PTSD with secondary 
alcoholism is granted.

Entitlement to service connection for hypertension to include 
as secondary to service-connected PTSD with secondary 
alcoholism is granted.  



____________________________________________
John E. Ormond, Jr.
Veterans Law Judge, Board of Veterans' Appeals


 Department of Veterans Affairs