Citation Nr: 0406178 Decision Date: 03/09/04 Archive Date: 03/19/04 DOCKET NO. 02-20 062A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to a rating in excess of 60 percent for arteriosclerotic cardiovascular disease. 2. Whether new and material evidence has been submitted to reopen claims of entitlement to service connection for beriberi and/or malnutrition. 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for hypertension. 4. Entitlement to service connection for dysentery. 5. Entitlement to service connection for a kidney disorder. 6. Entitlement to service connection for malaria. 7. Entitlement to service connection for special monthly compensation based on the need for regular aid and attendance or being housebound. ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The veteran had active military service from December 1941 to September 1942 and from September to December 1945, and was a prisoner of war (POW) of the Japanese government from April 10, 1942, to September 25, 1942. This matter comes to the Board of Veterans' Appeals (Board) on appeal from March and June 2002 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. In a September 1986 decision, the Board, in pertinent part, denied the veteran's claims for service connection for arteriosclerotic cardiovascular disease and essential hypertension, pulmonary disease, a urinary tract infection, and beriberi and/or malnutrition. That determination is final, and may not be reopened without evidence deemed to be new and material. In a June 1997 decision, the RO granted service connection for ischemic heart disease (arteriosclerotic cardiovascular disease) and awarded a 60 percent disability rating. The current appeal comes before the Board from the RO rating decisions of March and June 2002 which again, in pertinent part, denied service connection for hypertension and beriberi and/or malnutrition, and granted entitlement to a total rating based upon individual unemployability due to service-connected disability (TDIU). The Board points out in this regard that it appears that, in March and June 2002, the RO reopened the veteran's claims for hypertension and beriberi and/or malnutrition and denied them on the merits. However, before the Board may reopen a previously denied claim, it must conduct an independent review of the evidence to determine whether new and material evidence has been submitted sufficient to reopen a prior final decision. See Barnett v. Brown, 8 Vet. App. 1 (1995); 83 F.3d 1380 (Fed.Cir. 1996). Furthermore, if the Board finds that new and material evidence has not been submitted, it is unlawful for the Board to reopen the claim. See McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). Consequently, the first issue that must be addressed by the Board is whether the previously denied claims ought to be reopened. 38 U.S.C.A. § 5108 (West 2002). Also, the March 2002 rating decision denied entitlement to service connection for a urinary tract infection, and the veteran has not perfected an appeal as to that matter. However, in a lengthy November 2003 written statement, the veteran appears to raise claims of entitlement to service connection for a urinary tract disorder and pulmonary tuberculosis. These claims are referred to the RO for appropriate development and consideration. The veteran's appeal as to the matter of entitlement to service connection for a kidney disorder is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. VA will provide notification if further action is required on the part of the veteran. FINDINGS OF FACT 1. The objective and competent medical evidence of record fails to demonstrate that the veteran has definite heart enlargement or chronic congestive heart failure. 2. The objective and competent medical evidence of record fails to demonstrate that a workload of 3 metabolic equivalents (METs) or less results in dyspnea, fatigue, angina, dizziness, or syncope. 3. The objective and competent medical evidence of record fails to demonstrate that the veteran has an ejection fraction of less than 30 percent. 4. The veteran was a POW from April 10 to September 25, 1942. 5. The evidence added to the record since the September 1986 Board decision does not bear directly and substantially upon the specific matters under consideration regarding service connection for hypertension, beriberi, and/or malnutrition, and is cumulative of evidence previously considered, is not both new and material, and is not so significant that it must be considered in order to fairly decide the merits of the claims. 6. The preponderance of the competent and objective medical evidence of record fails to demonstrate that the veteran currently has residuals of dysentery incurred during active military service. 7. The preponderance of the competent and objective medical evidence fails to demonstrate that the veteran currently has residuals of malaria incurred during active military service or that any currently diagnosed malaria is due to active service. 8. The veteran's service-connected heart disease does not render him in need of regular aid and attendance, nor does it render him housebound. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 60 percent for arteriosclerotic cardiovascular heart disease are not met. 38 U.S.C.A. §§ 1155, 5100-5103A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.303 102, 3.159, 4.7, 4.104, Diagnostic Code 7005 (2003). 2. The September 1986 Board decision that denied entitlement to service connection for essential hypertension, beriberi, and/or malnutrition is final, and new and material evidence has not been submitted to reopen the claims of entitlement to service connection for hypertension, beriberi, and/or malnutrition. 38 U.S.C.A. §§ 5103, 5103A, 5106, 5107, 5108, 7104(b), 7105 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.300, 3.303, 20.1100, 20.1105 (2003). 3. Neither malaria nor dysentery was incurred in or aggravated by active service, nor may either disorder be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5100-5013A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2003). 4. The criteria for entitlement to special monthly compensation based on the need for aid and attendance or housebound status have not been met. 38 U.S.C.A. §§ 1114, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.350, 3.352 (2003). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters - Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code and, among other things, eliminated the requirement of a well-grounded claim and enhanced the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2003)). In addition, VA has published regulations to implement many of the provisions of the VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2003)). The Board is aware that there has been a significant amount of analysis pertaining to the effective date, the scope, and the remedial aspects of the VCAA. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1344 (Fed. Cir. 2003) (but see Public Law No. 108-183, § 701, 117 Stat. 2651, ___ (Dec. 16, 2003); Conway v. Principi, 353 F.3d 1359 (Fed. Cir. 2004); Pelegrini v. Principi, ___ Vet. App. ___, No. 01-944 (Vet. App. Jan. 13, 2004). See also VAOPGCPREC 11-00 (Nov. 27, 2000); VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 8- 2003 (Dec. 22, 2003). Given the uncertainty as to the precise application of the VCAA, exemplified in the authorities cited above, the Board assumes that the VCAA is applicable to this appeal. The Board further finds that the requirements of the VCAA have been satisfied in this matter. In July 2001, the RO provided the veteran with correspondence clearly outlining the duty-to-assist requirements of the VCAA regarding his claims for service connection for hypertension, a kidney disorder, malaria, and beriberi. In an August 2001 letter, the RO advised the veteran of its efforts to obtain pertinent medical evidence and of what the veteran should to obtain medical evidence to support his claims. In addition, the appellant was advised, by virtue of a detailed September 2002 statement of the case (SOC) issued during the pendency of this appeal, of the pertinent law, and what the evidence must show in order to substantiate his claims. We, therefore, believe that appropriate notice has been given in this case. The Board notes, in addition, that a substantial body of lay and medical evidence was developed with respect to the veteran's claims, and that the SOC issued by the RO clarified what evidence would be required to establish service connection. The veteran responded to the RO's communications with additional evidence and argument, thus curing (or rendering harmless) any previous omissions. Further, the claims file reflects that the July 2001 VCAA letter and September 2002 SOC contained the new duty-to- assist law and regulation codified at 38 U.S.C.A. § 5107 (West 2002) and 38 C.F.R. § 3.159 (2002). See Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). The Board concludes that the notifications received by the appellant adequately complied with the VCAA and subsequent interpretive authority, and that he has not been prejudiced in any way by the notice and assistance provided by the RO. See Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993), infra; VAOPGCPREC 16-92 (57 Fed. Reg. 49,747 (1992)). Likewise, it appears that all obtainable evidence identified by the veteran relative to his claims has been obtained and associated with the claims file, and that he has not identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. Accordingly, we find that VA has satisfied its duty to assist the veteran in apprising him as to the evidence needed, and in obtaining evidence pertaining to his claims, under both former law and the VCAA. The Board, therefore, finds that no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the veteran. The U.S. Court of Appeals for Veterans Claims has held that such remands are to be avoided. See Winters v. West, 12 Vet. App. 203 (1999) (en banc), vacated on other grounds sub nom. Winters v. Gober, 219 F.3d 1375 (Fed. Cir. 2000); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In fact, the Court has stated, "The VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims." Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc). Moreover, although 38 C.F.R. § 19.31(b)(1) (2003) would ordinarily require the RO to issue a supplemental statement of the case (SSOC) in response to new evidence, the Board notes that the medical evidence it received in November 2003 from the veteran provides no new information regarding the claimed disorders. The findings merely repeat those of the previous examination reports. Furthermore, the Board notes that it will not rely upon this evidence in making its decision in this case. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance in the 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 2002); 38 C.F.R. § 3.102 (2003). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that a veteran need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that 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. II. New and Material Evidence The Board, in a decision dated in September 1986, in pertinent part, denied the veteran's claims for service connection for essential hypertension, beriberi, and/or malnutrition. The Board found at that time that arteriosclerotic cardiovascular disease, including essential hypertension, was not shown until the 1980s and, although a private physician had recently diagnosed beriberi, the disease was not shown at during the veteran's 1985 VA examination and there was no corroborating clinical evidence provided by the veteran's private physician to support the diagnosis. The Board also noted that neither beriberi nor another nutritional deficiency disease was shown when the veteran was examined for separation in 1945, and there was essentially no evidence of record linking the claimed disorders to the veteran's active military service. The appellant was duly notified of the Board's action and the decision was, therefore, final, based upon the evidence then of record. 38 U.S.C.A. §§ 7104(b), 7105; 38 C.F.R. §§ 20.1100, 20.1105. The evidence of record before the Board at the time of its September 1986 decision included the veteran's service medical and personnel records. On September and October 1945 Affidavits for Philippine Army Personnel, the veteran indicated that he had no wounds or illnesses during service. When examined for separation in December 1945, beriberi, and/or malnutrition were not reported, and his blood pressure was 112/72. Also before the Board when it denied the veteran's claim for service connection for beriberi and/or malnutrition was a January 1984 written statement from D.F.M., M.D., indicating that he examined the veteran in December 1982. Diagnoses were not referable to beriberi and/or malnutrition. A January 1984 statement from R.A.C., M.D., diagnosed rheumatoid arthritis and possible heart disease. A February 1984 statement from J.A.L., M.D., is to the effect that he treated the veteran for shortness of breath and chest pain, but the physician did not describe beriberi and/or malnutrition. A February 1985 VA psycho-social evaluation report includes the veteran's report of being afflicted with beriberi, malaria, and dysentery as a POW and that he was released in September 1942 in a relatively weak and malnourished state. He was hospitalized in 1956 due to a nervous breakdown and in 1978 due to kidney and gall bladder problems, and had recently experienced blurred vision. The VA social worker noted that he looked haggard. In April 1985, the veteran underwent a VA former-POW protocol examination. On a report of medical history completed at that time, he indicated that as a POW he had experienced sores at the angles of his mouth, excessive thirst, vitamin deficiency, aches and pains in his muscles and joints, and beriberi. His blood pressure was 150/98. The pertinent diagnoses of the POW examination reflected arteriosclerotic hypertensive cardiovascular disease and no medical evidence of the current existence of any nutritional deficiency resulting from forced labor or inhumane treatment while a POW. In a September 1985 written statement, E.B.V., M.D., said that he had treated the veteran for chest pain, upper and lower extremity numbness, and dizziness. It was noted that the veteran was a POW and developed a nutritional deficiency, nervousness, and anxiety that caused loss of appetite and sleep up to the current time. The veteran was described as fairly well developed and fairly well nourished. Pertinent diagnoses included severe anemia and beriberi. The Board also considered the testimony of the veteran and his wife at his June 1986 personal hearing at the RO. The September 1986 Board decision was final based upon the evidence then of record. However, the claim will be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). If the Board determines that the evidence is new and material, the case is reopened and evaluated in light of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). In making this determination, the Board must look at all of the evidence submitted since the time that the claim was finally disallowed on any basis, not only since the time that the claim was last disallowed on the merits. In the present case, this means that the Board must look at all the evidence submitted since the September 1986 Board decision which was the final adjudication that disallowed the appellant's claims. New and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration which is neither cumulative nor redundant and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). See Hodge v. West, 155 F.3d. 1356 (Fed. Cir. 1998). Evidence that is solely cumulative or repetitious in character will not serve as a basis for reconsideration of a previous decision. Moreover, Hodge stressed that under the regulation new evidence could be material if that evidence provided "a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Hodge, supra, at 1363. As noted above, the VCAA contains extensive provisions modifying procedures for the adjudication of all pending claims. Of significance in the present matter, is language in the VCAA that provides: Rule with respect to disallowed claims.-Nothing in this section shall be construed to require the Secretary to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in section 5108 of this title. 38 U.S.C.A. § 5103A(f) (West 2002). Clearly, therefore, to whatever extent the new legislation has changed the approach to developing evidence in claims, it has not modified the longstanding requirement that a previously denied claim may not be reopened and readjudicated unless, and until, there has been a finding that new and material evidence has been submitted. Amendments to 38 C.F.R. § 3.156(a) that define new and material evidence are effective prospectively for claims filed on or after August 29, 2001. See 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) (now codified at 38 C.F.R. § 3.156(a)). Since the appellant's request to reopen his claim was filed in August 2000, the regulations in effect prior to August 29, 2001, are for application. An application to reopen the appellant's claims was received by the RO in August 2000. The evidence added to the record since the September 1986 Board decision that denied service connection for hypertension, beriberi, and/or malnutrition includes private medical records and statements, VA examination reports, and the veteran's written statements. In a July 1996 written statement, R.C.A., Jr., M.D., indicated that he had treated the veteran for the past two weeks for chest pains, headache, and breathing difficulty. Diagnoses included beriberi and hypertension. February 1997 VA examination reports indicate that the veteran was 167 centimeters (cm.) tall and weighed 74 kilograms (kg.). He complained of frequent dizziness, and his blood pressure was 150/80. The VA examiner diagnosed no residuals of malnutrition and no residuals of beriberi. In a January 1998 written statement, Dr. R.C.A. said he had treated the veteran for the past year for diagnoses that included hypertension. The doctor said the veteran's ailments were incurred as a POW, when he suffered from malnutrition and edema due to beriberi which may have resulted in beriberi heart disease, a urinary tract infection, and the beginning of optic nerve atrophy. Dr. R.C.A. said the veteran's ailments rendered him practically disabled, he was unable to do self-care, and his partial blindness and constant dizziness kept him nearly bedridden. A March 1998 VA examination report indicates that the veteran was 169 cm. tall and weighed 79 kg. Diagnoses included hypertensive arteriosclerotic heart disease. An October 2000 VA examination report indicates that he was 168.5 cm. tall and weighed 73.5 kg. In a July 1998 written statement, Dr. R.C.A. diagnosed the veteran with hypertension. An October 2000 VA examination report included a diagnosis of "HCVD" (hypertensive cardiovascular disease). In a February 2001 written statement, Dr. R.C.A. stated that since 1987 the veteran had suffered from diagnoses that included hypertension and beriberi, and that original records were sent to VA in 1989. Dr. R.C.A. said the veteran was still being treated for the listed disorders. The veteran underwent VA examination for infectious diseases in May 2002. According to the examination report, he alleged that he had beriberi, malnutrition, and dysentery as a POW and was treated by a private physician after his release as a POW. He complained of chest heaviness and easy fatigue with shortness of breath. He currently weighed 73.3 kg. There was no dermatitis or stomatitis noted. Upon examination, the VA examiner diagnosed no residual evidence of malnutrition, dysentery, or beriberi. The May 2002 VA examination report for aid and attendance reflects that the veteran's nutritional state was fairly nourished. The diagnosis was "HASHD" (hypertensive arteriosclerotic heart disease). In a June 2002 written statement, Dr. R.C.A. reported the veteran's complaints of chest pain, easy fatigability, and headache with difficulty breathing. Diagnosis included hypertension. The evidence added to the file in the context of the attempt to reopen the claim of entitlement to service connection for hypertension, beriberi, and/or malnutrition essentially fails to address the inadequacies of the appellant's claims at the time of the prior denial in September 1986. In this respect, the additional evidence submitted does not suggest that the veteran had hypertension, beriberi, and/or malnutrition due to service, and the recent VA and non-VA medical records do not support the appellant's contentions that such disorders were incurred in or related to his period of active service. Even assuming, arguendo, that the appellant's claims for service connection for hypertension, beriberi, and/or malnutrition were to be reopened and considered on the merits, the claims would still fail. Pursuant to 38 U.S.C.A. § 1110, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by service. Even if there is no record of hypertension in service, its incurrence in service will be presumed if it was manifest to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. Id. The United States Court of Appeals for Veterans Claims has consistently held that, under the law cited above, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the United States Court of Appeals for the Federal Circuit, which has stated, "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). It is clear that "[t]he regulations regarding service connection do not require that a veteran must establish service connection through medical records alone." Triplette v. Principi, 4 Vet. App. 45, 49 (1993), citing Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). It is equally clear, however, that the resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, require professional evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). In addition to the law and regulations regarding service connection, the Board notes that a disease specific to former POWs listed in 38 C.F.R. § 3.309(c) will be considered to have been incurred in service under the circumstances outlined in that section, even though there is no evidence of such disease during such period of service. 38 C.F.R. § 3.307(a). If a veteran is a former POW and was interned or detained for not less than 30 days, the following diseases shall be service-connected if manifest to a degree of 10 percent or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service, provided the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: avitaminosis; beriberi (including beriberi heart disease); chronic dysentery; helminthiasis; malnutrition (including optic atrophy associated with malnutrition); pellagra; any other nutritional deficiency; irritable bowel syndrome; and, peptic ulcer disease. 38 U.S.C.A. §§ 1110, 1112(b), 1113; 38 C.F.R. §§ 3.1(y), 3.307(a)(5), 3.309(c) (2003). For purposes of this section, the term beriberi heart disease includes ischemic heart disease in a former prisoner of war who had experienced localized edema during captivity. 38 C.F.R. § 3.309(c). The Board observes that, where a former POW claims disability compensation, omission of history or findings from clinical records made upon repatriation is not determinative of service connection, particularly if evidence of comrades in support of the incurrence of that disability during confinement is available. Special attention will be given to any disability first reported after discharge, especially if poorly defined and not obviously of intercurrent origin. The circumstances attendant upon the individual veteran's confinement, and the duration thereof, will be associated with pertinent medical principles in determining whether disability manifested subsequent to service is etiologically related to the POW experience. 38 C.F.R. § 3.304(e) (2003). The veteran was a former POW and, as a combat veteran, the veteran is entitled to have any statement or testimony of relevant symptoms he presents accepted as satisfactory evidence of that incurrence. See 38 U.S.C.A. § 1154(b) (West 2002). (The Board is assuming for the purpose of our analysis that the veteran, as a former POW, had engaged in combat with the enemy.) The evidence of record indicates that, as noted above, the veteran indicated on his 1985 POW medical history questionnaire on file that he suffered from malnutrition and beriberi as a POW. More important, however, the VA examiner at that time specifically reported that there was no medical evidence of any current disability resulting from nutritional deficiencies, forced labor, or inhumane treatment while a POW. The veteran has contended that service connection should be granted for hypertension, malnutrition, and beriberi due to his POW experience in service. But the record demonstrates that no hypertension, malnutrition, or beriberi was reported on his September and October 1945 processing affidavits, when he denied having wounds or illness on active duty, and December 1945 physical examination findings were normal. Moreover, the first post-service evidence of record of treatment for hypertensive is from the 1980s, nearly 40 years after the veteran's discharge from service. Furthermore, on VA examinations after the veteran's separation from service, there was no showing that the veteran had malnutrition or beriberi. In fact, in February 1997 and May 2002, two VA examiners specifically noted that while the veteran alleged to have beriberi and malnutrition there were no current residuals of these disorders evident. More important, the veteran submitted no medical evidence of a currently diagnosed residual of malnutrition or beriberi. See Degmetich v. Brown, 104 F.3d 1328, 1331-33 (Fed. Cir. 1997) (claimant must have disability at time of application for benefits, and not merely history of findings in service). In short, no medical opinion or other medical evidence showing that the veteran currently has residuals of malnutrition, beriberi, or dysentery been presented. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Nor do Dr. R.C.A.'s 1998 statement that the veteran had hypertension due to his POW experience, and the 2001 statement to the effect that the veteran was treated for beriberi since 1987, support the veteran's claim. Although the physician indicated that supporting records were supplied to VA in 1989, there is no indication in the claims file that such records were ever received at the RO. With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Further, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Here, as was the case at time of the Board's 1986 decision, the medical evidence fails to demonstrate that the veteran has hypertension, beriberi, and/or malnutrition as a result of active military service. The veteran is certainly capable of providing evidence of symptomatology, but a layperson is generally not capable of opining on matters requiring medical knowledge, such as the degree of disability produced by the symptoms or the condition causing the symptoms. See Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Espiritu v. Derwinski, 2 Vet. App. at 494 (1992). See also Routen, supra; Harvey v. Brown, 6 Vet. App. 390, 393-94 (1994). Here, the veteran has not submitted any medical opinion or other medical evidence that supports his claims. The evidence now of record fails to show that the veteran currently has hypertension, malnutrition, or beriberi related to service or to a service-connected disability. Thus, these claims must be denied. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(a); 38 C.F.R. § 3.303, 3.307, 3.309. In addition, the veteran does not meet the burden of presenting evidence as to medical cause and effect, or a diagnosis, merely by presenting his own testimony and that of his family and/or associates because, as laypersons, neither he nor they are competent to offer medical opinions. The Court of Appeals for Veterans Claims has made this clear in numerous cases. See, e.g., Espiritu v. Derwinski, 2 Vet. App. at 495; see also Routen v. Brown, supra. In other words, without our doubting for a moment the sincerity of the veteran's accounts of POW experience, we must be mindful that only medical professionals may make valid medical assessments of his condition, his current disability, and the etiology thereof. Consequently, the Board finds that the evidence received since the September 1986 Board decision regarding the claims for service connection for hypertension, beriberi, and/or malnutrition is cumulative of the evidence previously considered by the RO and not sufficiently significant to warrant reconsideration of the merits of the claims on appeal. As the evidence received since the September 1986 Board decision to deny service connection for hypertension, beriberi, and/or malnutrition is not new and material, it follows that the claims for service connection for hypertension, beriberi and/or malnutrition may not be reopened. III. Service Connection for Malaria and Dysentery, Increased Rating for Heart Disease, and Special Monthly Compensation (SMC) based on the Need for Regular Aid and Attendance or Being Housebound A. Factual Background Service medical records do not include an enlistment examination report. On September and October 1945 processing affidavits, the veteran indicated having no wounds or illness during service. When he was examined for separation in December 1945, neither malaria nor dysentery was noted. Post-service, the January and February 1984 written statements from Drs. D.F.M. and R.A.C. are not referable to malaria or dysentery The February 1985 VA psycho-social evaluation report includes the veteran's report of being afflicted with beriberi, malaria, and dysentery as a POW and that he said he was released in September 1942 in a relatively weak and malnourished state. He was hospitalized in 1956 due to a nervous breakdown and in 1978 due to kidney and gallbladder problems and recently experienced blurred vision. The VA social worker reported that the veteran looked haggard at the time of the evaluation. The veteran underwent a VA former POW protocol examination in April 1985. On a report of medical history completed at that time, he indicated that as a POW, he experienced sores at the angles of his mouth, excessive thirst, vitamin deficiency, aches and pains in his muscles and joints, dysentery, and beriberi. The pertinent diagnoses of the POW examination reflected no medical evidence of the current existence of any nutritional deficiency resulting from forced labor or inhumane treatment while a POW. The September 1985 statement from Dr. E.B.V. diagnosed beriberi and anemia but is not referable to dysentery or malaria. In a July 1996 medical certificate, R. C.A., Jr., M.D., said he treated the veteran for the past two weeks for chest pains, headache, and dizziness and urinary problems. Diagnoses were not referable to dysentery or malaria. The veteran underwent VA examination for systemic conditions in February 1997 but the diagnoses are not referable to dysentery or malaria. As noted above, in a June 1997 rating decision, the RO granted service connection for ischemic heart disease (arteriosclerotic cardiovascular disease) and awarded a 60 percent disability evaluation. In a January 1998 written statement Dr. R.C.A. said he treated the veteran for one year for ailments that included left ventricular hypertrophy and left lateral wall ischemia as shown by electrocardiogram (EKG) performed in January 1998, hypertension, minimal pulmonary tuberculosis (seen on X-ray in January 1998), partial blindness and a urinary tract infection. Dr. R.C.A. said the veteran's ailments were incurred while he was a POW when he suffered from malnutrition and edema due to beriberi that may have resulted in beriberi heart disease and optic nerve atrophy. It was noted that the veteran's partial blindness and constant dizziness kept him partially in bed. Dr. R.C.A.'s treatment records, dated from February to July 1998, are not referable to complaints of or treatment for malaria or dysentery. A private echocardiogram report dated in March 1998 reflects an ejection fraction of 66 percent (normal was 55-83%). The radiological interpretation revealed that the veteran's left ventricle appeared concentrically hypertrophied but there was adequate systolic function. In March 1998, the veteran underwent VA examination for heart and hypertension. The examination report indicates that the veteran, who was 77 years old, complained of chest pain and occasional edema. There was no evidence of congestive heart failure. It was noted that an EKG was normal and a chest X- ray showed a normal-size heart. Examination of the veteran's heart revealed no thrills and there was regular rhythm and normal S1, S2, and (-) S3 with no cardiac arrhythmia. Exercise tests reflected 3-4 METS. More than sedentary employment was not considered feasible. A July 1998 statement from Dr. R.C.A. reflects diagnoses of hypertension, left ventricular hypertrophy (rechecked by EKG in July 1998), minimal pulmonary tuberculosis (shown by January 1998 x-ray), partial blindness due to cataracts and urinary tract infection. A copy of the recent EKG results was enclosed. In a January 1999 rating decision, the RO denied an increased rating for the veteran's ischemic heart disease and entitlement to a TIDU and SMC. A March 2000 private chest X-ray report showed mild cardiomegaly and atheromatous aorta. In August 2000, the RO received the veteran's current claim for an increased rating for his service-connected heart disease. An October 2000 VA examination report reflects review of the veteran's March 1998 VA examination report and Dr. R.C.A. July 1998 medical certificate that diagnosed hypertension, left ventricular hypertrophy, pulmonary tuberculosis, and partial blindness due to cataract. It was noted that, since the last VA examination, the veteran had recurrent sharp chest pains, described as mild to moderate, experienced on waking up, that occurred twice a month and were relieved by moving the covers or taking medication. He was currently able to walk for 50 meters and do mild arm exercises. In March 2000 he experienced sudden dizziness followed by loss of consciousness for 10 minutes and was hospitalized for three days. He was told he had elevated blood pressure and heart disease but did not recall his prescribed medication. After his hospital discharge, he still felt weak and decided to seek hospitalization in another facility for there days and there was no change in prescribed medication. His other symptoms included recurrent dizziness related to changes in position, intermittent palpitations, easy fatigability and shortness of breath with moderate effort with right thigh numbness. He was able to tolerate slow walking up to 50 meters and was able to cook food for him and his wife. He had no orthopnea and no paroxysmal nocturnal dyspnea. On examination, there was no venous engorgement in the neck. Examination of the heart revealed that an "AB" (apical beat?) was not palpable; there was normal S1 and S2 and no murmur. There were clear breath sounds in the veteran's lungs and no edema. The VA examiner noted that the veteran was not in failure and tests reflected an ejection fraction of 66% with 4 METs. The diagnosis was hypertensive cardiovascular disease. More than light manual labor was not thought feasible because of the veteran's current symptomatology. The VA examiner said that more than ordinary effort such as that related to farming or employment that entailed physical effort may precipitate symptoms. A February 2001 written statement from Dr. A.A.D.S. is not referable to malaria, dysentery, or the veteran's service- connected heart disability. In a February 2001 written statement, Dr. R.C.A. said that since 1987 the veteran suffered from diagnoses that included ischemic heart disease, hypertension, left ventricular hypertrophy (shown on EKG as of July 1998), pulmonary tuberculosis, minimal shown on X-ray in January 1998, partial blindness due to cataracts, urinary tract infection, malaria, and beriberi. Dr. R.C.A. said he treated the veteran for the disorders but records of his hospitalization at Penafrancia Hospital were unavailable as they were destroyed in floods. Dr. R.C.A. said the veteran was seen regularly at the physician's clinic for treatment. In March 2001, the RO received the veteran's current claim for SMC and for service connection for malaria, dysentery, malnutrition, and beriberi. A July 2001 written statement from Dr. P.C. L. indicates the veteran was evidently hospitalized due to easy fatigability and hypogastric pain. Diagnoses included cardiac arrhythmia, bilateral renal cyst and bilateral nephrolithiases. In a December 2001 written statement, and again in February 2002, E.C-L., M.D., diagnosed cardiac arrhythmia and nephrolithiasis. In a February 2002 written statement, Dr. A.A.D.S. said the veteran was hospitalized for unstable angina secondary to coronary artery disease, hyperuremia, and multiple nephrolithiasis. In its March 2002 rating decision, the RO granted the veteran's claim for a TDIU, effective from August 2000. In May 2002, the veteran, who was 82 years old, underwent a VA examination for infectious diseases. According to the examination report, he alleged that he had beriberi, malnutrition, and dysentery in a concentration camp. He described having pedal edema, body weakness, and a puffy face when he was released as a POW and that a private doctor treated him on his release. The veteran complained of chest heaviness, joint pains, easy fatigue, shortness of breath, and blurred vision. He appeared conscious and alert, was clad in a clean shirt, and was sickly looking. Examination of the heart revealed regular rhythm, with no murmurs and an AB was not palpable; S1 and S2 were normal. His lungs were clear with no rales. The veteran's abdomen was soft with no tenderness and there was no pedal edema. The diagnoses included no residual evidence of malnutrition, dysentery and beriberi. The VA examiner said the veteran was 82 years old with multiple ailments involving his joints, kidneys, heart and vision. His poor vision and multiple joint pains, that on flare up caused difficulty in ambulating, were contributory factors in his being helpless. The veteran's heart condition and blood pressure elevation added to the above. Also in May 2002, the veteran underwent VA examination for aid and attendance or housebound status. According to the examination report, a March 2000 X-ray showed cardiomegaly, mild and atheromatous aorta, and a March 2001 kidney ultrasound showed bilateral nephrolithiasis and bilateral renal cyst. The veteran complained of chest pains, shortness of breath, easy fatigue, poor vision, and joint pains. It was noted that the veteran required his wife's assistance to report for the examination. The veteran was last hospitalized in February 2001 due to chest pains, shortness of breath and elevated blood pressure. He was not permanently bedridden. His pupils were reactive to light and positive for lens opacity. Right eye vision was count fingers at one foot; left eye vision was 15/200. It was noted that the veteran's memory was adequate, he was relevant in his answers, his judgment was good, and he was mentally competent to handle his funds. It was noted that he had dizziness whenever he stood up and walked and had to hold on to a chair and his cane when he walked. He preferred to stay at home, listening to the radio and sometimes walked around his house if not in pain. On examination, the veteran was conscious and sick looking, and was clad in a clean shirt. He was 5 feet 5 inches tall and weighed 161 pounds. He was stooped and fairly developed and nourished. The veteran walked slowly with his cane. His blood pressure was 170/80. He was able to eat by himself if food was prepared, and was assisted in taking a bath and going to the bathroom. Examination of his lower extremities reflected that he experienced pain on both knees with slight limitation of motion due to pain. He used a cane to walk and had difficulty standing up. He experienced lumbosacral spine pain upon movement. He was able to walk 5 to 10 meters slowly with his cane and to hold on to another person or the walls when he walked. He attended mass on Sundays if he felt well enough, accompanied by his wife and children. He rode a tricycle to church. The diagnoses included hypertensive arteriosclerotic heart disease, left ventricular hypertrophy, not in failure, ejection fraction of 66% with 4 METs, and degenerative arthritis in the lumbosacral spine and knees. In a May 2002 written statement, Dr. M. D.-C. said she had treated the veteran since February 1997 for ischemic heart disease, treated with prescribed medication. In a June 2002 written statement, Dr. R.C.A. said the veteran was seen for complaints of severe chest pains, easy fatigability and headaches, and difficulty breathing. Diagnoses included left ventricular hypertrophy, myocardial ischemia, and hypertension. According to doctor, the veteran was unable to do any productive work and was unable to do self-care without aid or attendance due to his ailments. A July 2002 private medical record indicates that the veteran was hospitalized for one day and diagnosed with benign prostatic hypertrophy, renal failure, and acute gouty arthritis. B. Analysis 1. Increased Rating for Arteriosclerotic Heart Disease In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41 (2003) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the veteran's service medical records and all other evidence of record pertaining to the history of his service- connected disability, and has found nothing in the historical record that would lead to a conclusion that the current evidence of record is inadequate for rating purposes. In addition, it is the judgment of the Board that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories and findings pertaining to the disability at issue. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4 (2003). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Not all disabilities will show all the findings specified in the rating criteria but coordination of the rating with functional impairment is required. 38 C.F.R. § 4.21. 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. Although the evaluation of a service-connected disability requires a review of the veteran's medical history with regard to that disorder, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. 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 the current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The veteran's service-connected heart diseased is evaluated as 60 percent disabling under Diagnostic Code (DC) 7005, which evaluates arteriosclerotic heart disease. 38 C.F.R. § 4.104, DC 7005. A 60 percent evaluation will be assigned where there is more than one episode of acute congestive heart failure in the past year; or a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 60 percent. Id. A 100 percent evaluation will be assigned where there is chronic congestive heart failure or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. 1 MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity that results in dyspnea, fatigue, angina, dizziness or syncope may be used. 38 C.F.R. § 4.104, Note (2). The current rating criteria provide that myocardial infarction is rated 100 percent during and for three months following myocardial infarction documented by laboratory tests. Thus, under the current rating criteria for evaluating arteriosclerotic heart disease, in order to warrant a 100 percent rating, the objective medical evidence must show one of three criteria. One of the criteria is valvular heart disease resulting in chronic congestive heart failure. As discussed above, the evidence does not show congestive heart failure. Another of the criteria is a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. In October 2000, the veteran complained of sharp recurrent chest pain and the VA examiner reported that the veteran was able to slowly walk up to 50 meters and had no orthopnea or paroxysmal nocturnal dyspnea and the veteran's cardiac stress test showed a maximum workload of 3 to 4 METs. At the most recent VA examinations in May 2002, the veteran complained of chest heaviness, easy fatigue, and shortness of breath. He was only able to walk 5 to 10 meters slowly while holding on to another person or wall and using a cane and a maximum workload of 4 METs was noted. In no case was a workload of 3 METs or less reported such as to meet the criteria noted above under the current regulations. The last of the three criteria is left ventricular dysfunction with an ejection fraction of less than 30 percent. The March 1998 cardiac catherization report showed an estimated ejection fraction of 66 percent with left ventricular hypertrophy. Private medical statements have also diagnosed left ventricular hypertrophy. In October 2000, the VA examiner noted that tests reflected an ejection fraction of 66 percent. In May 2002, the VA examiner reported hypertensive arteriosclerotic heart disease and left ventricular hypertrophy with an ejection fraction of 66 percent. Accordingly, as the evidence does not show that the veteran meets any of the three criteria for a 100 percent rating under the current diagnostic code, his service- connected heart disability does not meet the requirements for a 100 percent schedular rating under the current diagnostic criteria. See 38 C.F.R. § 4.104, Diagnostic Code 7000. In sum, the Board finds that the preponderance of the evidence is against the veteran's claim for an increased rating for arteriosclerotic cardiovascular disease. See 38 U.S.C.A. §§ 1155, 5107 (new and old); 38 C.F.R. §§ 4.7, 4.104, DC 7005. Furthermore, as previously noted above, in March 2002, the RO awarded a total rating based upon individual unemployability due to service-connected disabilities. In this case, the Board finds that the preponderance of the objective medical evidence is against an increased rating, in excess of the present 60 percent, for arteriosclerotic cardiovascular disease. Moreover, the evidence is not so evenly balanced as to allow for the application of the reasonable-doubt doctrine. 38 U.S.C.A. § 5107(b) (old and new). 2. Service Connection According to 38 U.S.C.A. § 1110, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by service. As noted above, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson, Boyer, supra. Also, the resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, require professional evidence. See Espiritu, Routen, supra. In addition to the law and regulations regarding service connection, the Board notes that a disease specific to former POWs listed in 38 C.F.R. § 3.309(c) will be considered to have been incurred in service under the circumstances outlined in that section, even though there is no evidence of such disease during such period of service. 38 C.F.R. § 3.307(a). As also previously noted, if a veteran is a former POW and was interned or detained for not less than 30 days, the following diseases shall be service-connected if manifest to a degree of 10 percent or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service, provided the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: avitaminosis; beriberi (including beriberi heart disease); chronic dysentery; helminthiasis; malnutrition (including optic atrophy associated with malnutrition); pellagra; any other nutritional deficiency; irritable bowel syndrome; and, peptic ulcer disease. 38 U.S.C.A. §§ 1110, 1112(b), 1113; 38 C.F.R. §§ 3.1(y), 3.307(a)(5), 3.309(c). For purposes of this section, the term beriberi heart disease includes ischemic heart disease in a former prisoner of war who had experienced localized edema during captivity. 38 C.F.R. § 3.309(c). The Board observes that, where a former POW claims disability compensation, omission of history or findings from clinical records made upon repatriation is not determinative of service connection, particularly if evidence of comrades in support of the incurrence of that disability during confinement is available. Special attention will be given to any disability first reported after discharge, especially if poorly defined and not obviously of intercurrent origin. The circumstances attendant upon the individual veteran's confinement, and the duration thereof, will be associated with pertinent medical principles in determining whether disability manifested subsequent to service is etiologically related to the POW experience. 38 C.F.R. § 3.304(e). The veteran was a former POW and, as a combat veteran, the veteran is entitled to have any statement or testimony of relevant symptoms he presents accepted as satisfactory evidence of that incurrence. See 38 U.S.C.A. § 1154(b) (West 2002). (The Board is assuming, for the purpose of our analysis that the veteran, as a former POW, had engaged in combat with the enemy.) The evidence of record indicates that, as noted above, while the veteran indicated on his 1985 POW medical history questionnaire on file that he suffered from vitamin deficiency and dysentery he did not report having malaria. More important, the 1985 VA examiner specifically reported that there was no medical evidence of any current disability resulting from nutritional deficiencies, forced labor, or inhumane treatment while a POW. Furthermore, in May 2002, the VA examiner diagnosed no residuals of malaria or dysentery. Although private medical evidence dated in 2001 is to the effect that the veteran was treated for malaria since 1987, no competent medical evidence has been submitted to show that this disability is related to service or any incident thereof. On the other hand, the record reflects that malaria was not reported when the veteran was examined for separation from service in December 1945, and the first post-service evidence of record of treatment for malaria is from the February 2001 record from Dr. R.C.A. who said he treated the veteran for malaria since 1987, more than 42 years after the veteran's separation from service. In short, no medical opinion or other medical evidence relating the veteran's reported malaria to service or any incident of service has been presented. The veteran has also contended that service connection should be granted for dysentery. The record demonstrates that no dysentery was found in service or on separation from service. While the veteran checked "yes" to having dysentery at the time of his 1985 VA POW protocol examination, the examiner specifically reported that there was no medical evidence of any current disability resulting from nutritional deficiencies, forced labor, or inhumane treatment while a POW. Moreover, in May 2002, the VA examiner diagnosed no residuals of malaria or dysentery. Furthermore, the veteran has submitted no evidence to show that he currently has dysentery. In short, no medical opinion or other medical evidence showing that the veteran currently has dysentery has been presented. See Rabideau v. Derwiniski, 2 Vet. App. at 143. The veteran is certainly capable of providing evidence of symptomatology, but a layperson is generally not capable of opining on matters requiring medical knowledge, such as the degree of disability produced by the symptoms or the condition causing the symptoms. See Robinette v. Brown, 8 Vet. App. at 74; Heuer v. Brown, 7 Vet. App. at 384; Espiritu v. Derwinski, 2 Vet. App. at 494. See also Routen, supra; Harvey v. Brown, 6 Vet. App. at 393-94. Here, the veteran has not submitted any medical opinion or other medical evidence that supports his claim. The evidence now of record fails to show that the veteran currently has malaria or dysentery related to service or to a service-connected disability. Thus, these claims must be denied. 38 U.S.C.A. §§ 1101, 1110,1112, 1113, 5107(a); 38 C.F.R. §§ 3.303, 3.303, 3.307, 3.309. We have considered the doctrine of reasonable doubt. Under that doctrine, when there is an approximate balance between evidence for and against a claim, the evidence is in equipoise, there is said to be a reasonable doubt, and the benefit of such doubt is given to the claimant. 38 U.S.C.A. § 5107(b); see Schoolman v. West, 12 Vet. App. at 310-1; 38 C.F.R. § 3.102. However, when the evidence for and against a claim is not in equipoise, then there is a preponderance of evidence either for or against the claim, there is no reasonable doubt, and the doctrine is inapplicable. Hayes v. Brown, 5 Vet. App. at 69-70. 3. Special Monthly Compensation Special monthly compensation benefits are payable to a veteran who needs regular aid and attendance. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350. A veteran is in need of regular aid and attendance if he is helpless or so nearly helpless as to require the regular aid and attendance of another person. The criteria for establishing the need for aid and attendance include anatomical loss or loss of use of one or more extremities; consideration of whether the veteran is blind or is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or whether the veteran is a patient in a nursing home because of mental or physical incapacity; or whether the evidence establishes a factual need for aid and attendance or "permanently bedridden" status under the criteria set forth in 38 C.F.R. § 3.352(a). 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). Under the provisions of section 3.352(a), these criteria include the inability of the veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; whether he requires frequent adjustment of any special prosthetic or orthopedic appliances with the aid of another; inability to feed himself; inability to attend to the wants of nature; or incapacity, physical or mental, that requires assistance on a regular basis to protect himself from hazards or dangers incident to his daily environment. "Bedridden" will be a proper basis for the determination under this section. For the purposes of this section, "bedridden" constitutes a condition that through its essential character actually requires that an individual remain in bed. The fact that the veteran has voluntarily taken to bed or that a physician has prescribed bed rest for a lesser or greater portion of the day will not suffice. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. Also, SMC may be paid to a veteran in cases where that veteran has a single service-connected disability rated as 100 percent disabling and either (a) has an additional service-connected disability, or disabilities, independently rated as 60 percent disabling, which (i) is/are separate and distinct from the service-connected disability rated as 100 percent disabling and (ii) involve(s) different anatomical or bodily symptoms; or (b) is permanently housebound by reason of a service-connected disability or disabilities. The latter requirement is met when the veteran is substantially confined to his dwelling and the immediate premises as a direct result of service-connected disabilities, or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities will continue throughout the veteran's lifetime. 38 U.S.C.A. § 1114(s) (West. 2002); 38 C.F.R. § 3.350(i) (2003). The applicable laws and regulations contain no provision allowing for the consideration of nonservice-connected disabilities in the determination of housebound status for the purposes of SMC. Although the veteran need not show all of the disabling conditions identified in 38 C.F.R. § 3.352(a) to establish entitlement to aid and attendance, the Court of Appeals for Veterans Claims has held that it is logical to infer that there is a threshold requirement that "at least one of the enumerated factors be present." See Turco v. Brown, 9 Vet. App. 222, 224 (1996). In this case, contentions have been advanced to the effect that the veteran is in need of regular aid and attendance or that he is housebound. It is alleged that he cannot manage on his own, that he is unable to walk, and that he is desperately in need of help because his disabilities prohibit his ability to adequately care for himself. As indicated above, the veteran's service-connected disability results in a 60 percent evaluation. The May 2002 VA examinations revealed that the veteran was still able to feed and dress himself. While the examiner noted that the veteran walked slowly and with a cane and required assistance to bathe and use the bathroom, it was noted that the veteran had multiple ailments involving his joints, kidneys, heart and vision. The VA examiner indicated that the veteran's behavior in this regard resulted from his poor vision, multiple joint pains that on flare-ups caused ambulation difficulties and were contributory factors to his being helpless, for which service connection is not in effect, and not from his service-connected cardiovascular disease that, she said "added to the above". After careful review of the entire evidence of record, including statements dated in June 2002 from Dr. R.C.A. addressing the veteran's need for assistance, the Board concludes that the veteran is clearly shown to be in need of additional assistance. However, while the Board recognizes the severity of the veteran's disabilities and their impact on his daily life, the criteria for granting special monthly compensation benefits based on the need for regular aid and attendance are quite specific. The medical findings reported in the record, including the above statement from a private physician, does not demonstrate that the appellant is bedridden or that he is unable to take care of his personal needs (dressing, bathing, going to the bathroom, eating) on a regular basis as a consequence of his service-connected heart disease. Further, as noted, a total rating based upon individual unemployability due to service-connected disabilities has been in effect since August 2000. The veteran also has other diagnosed non-service-connected disorders that involve significant impairment. The June 2002 statement from Dr. R.C.A. is to the effect that the veteran was unable to perform self-care functions without problems. The Board does not doubt that the veteran's service-connected heart disability has resulted in a significant level of social and occupational impairment. However, the criteria for the need for aid and attendance under 38 C.F.R. § 3.352(a) simply have not been met in this case. Likewise, there is no indication that the veteran is confined to his dwelling and the immediate premises on account of his service-connected disability. As such, the record does not establish that the veteran is permanently housebound by reason of a service-connected disability or disabilities. Overall, the Board finds that the criteria for SMC on the basis of needing regular aid and attendance or being housebound have not been met in this case, and the claim of entitlement to SMC must be denied. As the preponderance of the evidence is against the veteran's claim for this benefit, the benefit-of-the-doubt rule of 38 U.S.C.A. § 5107(b) (West 2002) is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. at 55. ORDER A rating in excess of 60 percent for arteriosclerotic cardiovascular disease is denied. New and material evidence having not been submitted, the appellant's application to reopen the claims of entitlement to service connection for hypertension, beriberi, and/or malnutrition is denied. Service connection for dysentery is denied. Service connection for malaria is denied. Special monthly compensation based on the need for regular aid and attendance or being housebound is denied. REMAND As noted above, the VCAA, substantially modified the circumstances under which VA's duty to notify and assist claimants applies, and how that duty is to be discharged. 38 U.S.C.A. §§ 5100-5103A, 5106-7 (West 2002). VA has published regulations implementing many of the provisions of the VCAA. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2003). See VAOPGCPREC 7-2003 (Nov. 19, 2003), as to retroactivity of the VCAA regulations. Under the new law and regulations, first, VA has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. 38 U.S.C.A. § 5102 (West 2002); 38 C.F.R. § 3.159(b)(2) (2003). Second, VA has a duty to notify the claimant as to any information and evidence needed to substantiate and complete a claim, and as to what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) (2003); see Quartuccio v. Principi, supra; Charles v. Principi ,supra. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002); 38 C.F.R. § 3.159(c) (2003). In November 2003, the Board received a lengthy written statement from the veteran regarding his claims, with additional medical evidence, much of it duplicative of that previously received. However, two new records were submitted by the veteran: a record dated February 26, 2002, from Dr. M.A.C. indicates that the veteran was treated for a renal stone and hypertensive heart disease; and a July 3, 2003, record from Dr. P.N.T. indicates the veteran was treated for flank pain and diagnosed with nephrolithaiasis. The veteran did not provide a waiver of initial RO consideration of this new evidence. When additional evidentiary development is necessary, the RO, not the Board, must undertake the task. See Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1337 (Fed. Cir.2003). Thus, due process requires that this case be REMANDED to the RO for the following action: 1. The RO should review the claims file and ensure that all VCAA notice obligations have been satisfied in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A, (West 2002), and any other applicable legal precedent. Such notice should specifically apprise the veteran of the evidence and information necessary to substantiate his claim for service connection for a kidney disorder and inform him whether he or VA bears the burden of producing or obtaining that evidence or information, and of the appropriate time limitation within which to submit any evidence or information. 2. The veteran should be requested to provide the names and addresses of all VA and non-VA medical providers who have treated him for the kidney disorder at issue since July 2003. The RO should then request all pertinent medical records from these medical providers. 3. Thereafter, the RO should readjudicate the veteran's claim for service connection for a kidney disorder. If the benefits sought on appeal remain denied, the veteran and his representative should be provided with a supplemental statement of the case (SSOC). The SSOC should contain notice of all relevant actions taken on the claim, to include a summary of the evidence and applicable law and regulations considered pertinent to the issue currently on appeal since the September 2002 statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West 2002) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.43 and 38.02. ____________________________ ANDREW J. MULLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs YOUR RIGHTS TO APPEAL OUR DECISION The attached decision by the Board of Veterans' Appeals (BVA or Board) is the final decision for all issues addressed in the "Order" section of the decision. The Board may also choose to remand an issue or issues to the local VA office for additional development. If the Board did this in your case, then a "Remand" section follows the "Order." However, you cannot appeal an issue remanded to the local VA office because a remand is not a final decision. The advice below on how to appeal a claim applies only to issues that were allowed, denied, or dismissed in the "Order." If you are satisfied with the outcome of your appeal, you do not need to do anything. We will return your file to your local VA office to implement the BVA's decision. However, if you are not satisfied with the Board's decision on any or all of the issues allowed, denied, or dismissed, you have the following options, which are listed in no particular order of importance: ? Appeal to the United States Court of Appeals for Veterans Claims (Court) ? File with the Board a motion for reconsideration of this decision ? File with the Board a motion to vacate this decision ? File with the Board a motion for revision of this decision based on clear and unmistakable error. Although it would not affect this BVA decision, you may choose to also: ? Reopen your claim at the local VA office by submitting new and material evidence. There is no time limit for filing a motion for reconsideration, a motion to vacate, or a motion for revision based on clear and unmistakable error with the Board, or a claim to reopen at the local VA office. None of these things is mutually exclusive - you can do all five things at the same time if you wish. However, if you file a Notice of Appeal with the Court and a motion with the Board at the same time, this may delay your case because of jurisdictional conflicts. If you file a Notice of Appeal with the Court before you file a motion with the BVA, the BVA will not be able to consider your motion without the Court's permission. How long do I have to start my appeal to the Court? You have 120 days from the date this decision was mailed to you (as shown on the first page of this decision) to file a Notice of Appeal with the United States Court of Appeals for Veterans Claims. If you also want to file a motion for reconsideration or a motion to vacate, you will still have time to appeal to the Court. As long as you file your motion(s) with the Board within 120 days of the date this decision was mailed to you, you will then have another 120 days from the date the BVA decides the motion for reconsideration or the motion to vacate to appeal to the Court. You should know that even if you have a representative, as discussed below, it is your responsibility to make sure that your appeal to Court is filed on time. How do I appeal to the United States Court of Appeals for Veterans Claims? Send your Notice of Appeal to the Court at: Clerk, U.S. Court of Appeals for Veterans Claims 625 Indiana Avenue, NW, Suite 900 Washington, DC 20004-2950 You can get information about the Notice of Appeal, the procedure for filing a Notice of Appeal, the filing fee (or a motion to waive the filing fee if payment would cause financial hardship), and other matters covered by the Court's rules directly from the Court. You can also get this information from the Court's web site on the Internet at www.vetapp.uscourts.gov, and you can download forms directly from that website. The Court's facsimile number is (202) 501-5848. To ensure full protection of your right of appeal to the Court, you must file your Notice of Appeal with the Court, not with the Board, or any other VA office. How do I file a motion for reconsideration? You can file a motion asking the BVA to reconsider any part of this decision by writing a letter to the BVA stating why you believe that the BVA committed an obvious error of fact or law in this decision, or stating that new and material military service records have been discovered that apply to your appeal. If the BVA has decided more than one issue, be sure to tell us which issue(s) you want reconsidered. Send your letter to: Director, Management and Administration (014) Board of Veterans' Appeals 810 Vermont Avenue, NW Washington, DC 20420 VA FORM JUN 2003 (RS) 4597 Page 1 CONTINUED Remember, the Board places no time limit on filing a motion for reconsideration, and you can do this at any time. However, if you also plan to appeal this decision to the Court, you must file your motion within 120 days from the date of this decision. How do I file a motion to vacate? You can file a motion asking the BVA to vacate any part of this decision by writing a letter to the BVA stating why you believe you were denied due process of law during your appeal. For example, you were denied your right to representation through action or inaction by VA personnel, you were not provided a Statement of the Case or Supplemental Statement of the Case, or you did not get a personal hearing that you requested. You can also file a motion to vacate any part of this decision on the basis that the Board allowed benefits based on false or fraudulent evidence. Send this motion to the address above for the Director, Management and Administration, at the Board. Remember, the Board places no time limit on filing a motion to vacate, and you can do this at any time. However, if you also plan to appeal this decision to the Court, you must file your motion within 120 days from the date of this decision. How do I file a motion to revise the Board's decision on the basis of clear and unmistakable error? You can file a motion asking that the Board revise this decision if you believe that the decision is based on "clear and unmistakable error" (CUE). Send this motion to the address above for the Director, Management and Administration, at the Board. You should be careful when preparing such a motion because it must meet specific requirements, and the Board will not review a final decision on this basis more than once. You should carefully review the Board's Rules of Practice on CUE, 38 C.F.R. 20.1400 -- 20.1411, and seek help from a qualified representative before filing such a motion. See discussion on representation below. Remember, the Board places no time limit on filing a CUE review motion, and you can do this at any time. How do I reopen my claim? You can ask your local VA office to reopen your claim by simply sending them a statement indicating that you want to reopen your claim. However, to be successful in reopening your claim, you must submit new and material evidence to that office. See 38 C.F.R. 3.156(a). Can someone represent me in my appeal? Yes. You can always represent yourself in any claim before VA, including the BVA, but you can also appoint someone to represent you. An accredited representative of a recognized service organization may represent you free of charge. VA approves these organizations to help veterans, service members, and dependents prepare their claims and present them to VA. An accredited representative works for the service organization and knows how to prepare and present claims. You can find a listing of these organizations on the Internet at: www.va.gov/vso. You can also choose to be represented by a private attorney or by an "agent." (An agent is a person who is not a lawyer, but is specially accredited by VA.) If you want someone to represent you before the Court, rather than before VA, then you can get information on how to do so by writing directly to the Court. Upon request, the Court will provide you with a state-by-state listing of persons admitted to practice before the Court who have indicated their availability to represent appellants. This information is also provided on the Court's website at www.vetapp.uscourts.gov. Do I have to pay an attorney or agent to represent me? Except for a claim involving a home or small business VA loan under Chapter 37 of title 38, United States Code, attorneys or agents cannot charge you a fee or accept payment for services they provide before the date BVA makes a final decision on your appeal. If you hire an attorney or accredited agent within 1 year of a final BVA decision, then the attorney or agent is allowed to charge you a fee for representing you before VA in most situations. An attorney can also charge you for representing you before the Court. VA cannot pay fees of attorneys or agents. Fee for VA home and small business loan cases: An attorney or agent may charge you a reasonable fee for services involving a VA home loan or small business loan. For more information, read section 5904, title 38, United States Code. In all cases, a copy of any fee agreement between you and an attorney or accredited agent must be sent to: Office of the Senior Deputy Vice Chairman (012) Board of Veterans' Appeals 810 Vermont Avenue, NW Washington, DC 20420 The Board may decide, on its own, to review a fee agreement for reasonableness, or you or your attorney or agent can file a motion asking the Board to do so. Send such a motion to the address above for the Office of the Senior Deputy Vice Chairman at the Board. VA FORM JUN 2003 (RS) 4597 Page 2