Citation Nr: 0717662 Decision Date: 06/13/07 Archive Date: 06/26/07 DOCKET NO. 05-08 833 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Millikan Sponsler, Associate Counsel INTRODUCTION The veteran served on active military duty from June 1968 to December 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision by the St. Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA). FINDING OF FACT The competent medical evidence of record indicates that the veteran's hypertension is related to active service. CONCLUSION OF LAW Hypertension was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2006). REASONS AND BASES FOR FINDING AND CONCLUSION In November 2000, the Veterans Claims Assistance Act of 2000 (VCAA) was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2005); see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2006). Because the claim on appeal is being granted in full, the notification and duty to assist provisions of the VCAA are deemed fully satisfied. Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may 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). In addition, hypertension may be presumed to have been incurred during service if it first became manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.307, 3.309. In order to establish service connection for a claimed disorder, the following must be shown: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Additionally, service connection may be granted where a disability is determined to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. 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. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). By a December 2002 rating decision, the RO granted service connection for diabetes mellitus, type II, due to Agent Orange exposure during service. The veteran's service medical records are negative for hypertension. Subsequent to service discharge, a February 1979 VA medical record noted no blood pressure problems. Private medical records from August 2000 through April 2002 diagnosed diabetes mellitus and hypertension or elevated blood pressure. A November 2002 private physician statement indicated the veteran had been treated for diabetes mellitus, type II since August 2000. A January 2003 VA general medical examination was conducted upon a review of the claims file. The veteran reported that hypertension and diabetes were diagnosed in September 2000. Upon examination, the diagnoses included diabetes mellitus, type II and hypertension. The examiner concluded that hypertension was not related to the diabetes mellitus because hypertension was diagnosed at the same time as diabetes. A May 2003 VA peripheral nerves examination was conducted upon a review of the claims file. The diagnoses included diabetes mellitus type II, under adequate control. A January 2004 letter from a private physician noted that the veteran had been under his care for approximately 12 years and had not carried a hypertension diagnosis or had been treated for hypertension. A March 2004 letter from a private physician, J.D., M.D., opined that the veteran's hypertension was due to Agent Orange exposure and was related to diabetes. Dr. J.D. stated that he reviewed the veteran's medical records and noted there was no family history of hypertension. Dr. J.D. stated that medical literature demonstrated that Agent Orange results in insulin resistance and that this insulin resistance is the underlying cause of diabetes mellitus. Dr. J.D. also noted that a large body of evidence indicated that the insulin resistance syndrome caused diabetes mellitus and hypertension. Dr. J.D. thus opined that because there was no family history of hypertension, it was unreasonable to award service connection for diabetes and not for hypertension based on Agent Orange exposure. Dr. J.D. concluded that in his medical opinion, the veteran's hypertension was "due to his exposure to Agent Orange and related to his diabetes." In a February 2005 letter, Dr. J.D. stated that he reviewed the veteran's private treatment records. Dr. J.D. reiterated his opinion that the veteran's hypertension and diabetes mellitus were both due to insulin resistance syndrome, the underlying metabolic disorder that results from Agent Orange exposure. The examiner noted that the fact that hypertension and diabetes mellitus were diagnosed at the same time is evidence that they resulted from the same underlying disorder. In a February 2005 letter, P.M., M.D., the veteran's internist since 2000, when diabetes and hypertension were diagnosed, opined that hypertension was secondary to the insulin resistance, which has been shown to be connected to exposure to dioxins found in Agent Orange. Dr. P.M. stated that relevant research indicates that inflammatory markers produced by the insulin resistance promote endothelial dysfunction and atherogenesis, which set the hypertensive state and that medical literature clearly supports a causative relationship between insulin resistance and hypertension. The Board finds that the competent evidence of record supports a finding of service connection for hypertension. There is a current diagnosis of hypertension. Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Although there is no evidence of high blood pressure or hypertension during service, it is presumed that the veteran was exposed to Agent Orange during service. See 38 U.S.C.A. § 1116 (West 2002); see also Hickson, 12 Vet. App. at 253 (holding that service connection requires medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury). In addition, the other evidence of record indicates that the veteran's hypertension is related to active service, to include exposure to Agent Orange. Hickson, 12 Vet. App. at 253 (holding that service connection requires medical evidence of a nexus between the claimed in-service disease or injury and the current disability). Although a VA nurse practitioner stated that the veteran's hypertension was not related to diabetes mellitus, the examiner did not address whether the hypertension was related to active service, to include as due to Agent Orange exposure. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (noting that the question of whether a disability is etiologically related to active service requires competent medical evidence). Importantly, two private physicians opined that hypertension is due to inservice Agent Orange exposure. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board is not free to substitute its own judgment for that of such an expert). Dr. P.M., the veteran's internist since 2000, when the diagnoses of diabetes and hypertension were made, opined that the veteran's hypertension was secondary to the Agent Orange caused insulin resistance. Another private physician, Dr. J.D., opined that due to the lack of a family history of hypertension, inservice Agent Orange exposure, and a large body of evidence indicating that insulin resistance syndrome causes diabetes and hypertension, the veteran's hypertension was due to Agent Orange exposure. In another letter, Dr. J.D., upon another review of the veteran's private treatment records, opined that the diagnosis of hypertension and diabetes at the same time indicated they were both due to the same underlying metabolic disorder caused by Agent Orange exposure. The Board finds these medical opinions credible as they were supported by a review of the pertinent medical evidence and contain supporting clinical rationale. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board must assess the credibility and probative value of the medical evidence in the record); see also Prejean v. West, 13 Vet. App. 444, 448- 9 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). Accordingly, service connection for hypertension is granted. ORDER Service connection for hypertension is granted. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs