Citation Nr: 1414153 Decision Date: 04/01/14 Archive Date: 04/11/14 DOCKET NO. 09-21 364 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for a sleep disorder, to include as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran had active duty service from June 1982 to October 2005. This appeal to the Board of Veterans' Appeals (Board) arose from a July 2008 rating decision in which the RO, among other things, denied the Veteran's claim for service connection for sleep apnea (claimed as due to PTSD). In July 2008, the Veteran filed a notice of disagreement (NOD) with this rating decision. A statement of the case (SOC) was issued in May 2009, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in June 2009. In October 2013, the Board recharacterized the claim on appeal to encompass any sleep disorder and direct and secondary theories of entitlement (as reflected on the title page), and remanded the claim to the RO, via the Appeals Management Center (AMC) in Washington, DC, for additional development. After attempting to accomplish the requested action (the issuance of a notice letter to the appellant, the receipt of VA treatment records, and scheduling a VA examination), the AMC continued to deny each claim for service connection (as reflected in a January 2014 supplemental SOC (SSOC)), and returned this matter to the Board for further appellate consideration. This appeal was processed using the Virtual VA paperless, electronic claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. Pertinent lay and medical evidence of record collectively indicates that the Veteran has insomnia which was first manifested and treated during active service, and which has continued to date. 3. Sleep apnea was not shown until after service, and competent, persuasive opinion addressing the etiology of sleep apnea indicates that sleep apnea is not etiologically related to service, and was not caused or worsened by the Veteran's service-connected PTSD. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for insomnia are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303 (2013). 2. The criteria for service connection for sleep apnea, to include as secondary to PTSD, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (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 her or his possession that pertains to the claim(s), in accordance with 38 C.F.R § 3.159(b)(1) . The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service (or service-connected disability) and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In a December 2007 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for service connection, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The July 2008 RO rating decision reflects the initial adjudication of the claims after issuance of the December 2007 letter. In a subsequent November 2013 letter the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for service connection on a secondary basis. After issuance of the November 2013 letter, and opportunity for the Veteran to respond, the January 2014 SSOC reflects the most recent readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the electronic claims file consists of service treatment records, post-service private and VA treatment records, a June 2012 VA examination report, and a November 2013 VA examination report. Also of record and considered in connection with the appeal is the various written statements provided by the Veteran, and by his representative, on his behalf. The Board finds that no additional RO action to further develop the record in connection with this claim, prior to appellate consideration, is required. In particular, the Board finds that the VA examinations and medical opinions obtained in connection with these claims are adequate for and pertinent to its determinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In particular, the November 2013 examiner's opinion was based upon physical examination of the Veteran and complete review of the claims file, and was supported by fully explained medical and factual bases. Also, as noted above, the claim was previously remanded by the Board in October 2013. Significantly, the Board then noted that a medical opinion regarding matter of sleep apnea on a secondary basis was of record but that a medical opinion addressing a direct basis was needed, as well as a medical opinion regarding a sleep disorder other sleep apnea. Such opinions were obtained in November 2013. And, following the Board's October 2013 remand, recent VA treatment records were obtained and associated with the claims file. The Board finds that no further RO action on the claim, prior to appellate consideration, is required. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate the claim, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active peacetime service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). The diseases listed in section 3.309(a) do not include any sleep disorders. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit recently clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.310(a), service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310 (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 with regard to the requirements for establishing secondary service connection on an aggravation basis. See 71 Fed. Reg. 52,744 - 47 (Sept. 7, 2006). The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Notably, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. A lay claimant is competent to provide testimony concerning factual matters of which he or she has firsthand knowledge (i.e., reporting something seen, sensed or experienced). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In Barr, the United States Court of Appeals for Veterans Claims (Court) emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of the presence of the claimed symptomatology. However, there are clearly limitations regarding the competence of a lay claimant to speak to certain matters, such as those involving medical diagnosis and etiology. See Jandreau, 492 F.3d at 1377 (Fed. Cir. 2007) (noting that a layperson not competent to diagnose a form of cancer). As reflected in Fed.R.Evid 701, lay witness testimony is permissible in the form of opinions or inferences when (a) rationally based on the perception of the witness and (b) helpful to a clear understanding of the witness' testimony or the determination of a fact in issue. Otherwise, in matters involving scientific, technical or other specialized knowledge, Fed.R.Evid 702 requires that an opinion be provided by a witness qualified as an expert by knowledge, skill, experience, training or education. III. Analysis The Veteran claims that he first began experiencing sleep difficulties during active service. Specifically, the Veteran has reported that he began experiencing "trouble sleeping" beginning in 2003. Service treatment records document no complaint, finding, or diagnosis pertaining to sleep impairment. In reports of medical history dated in January 1982, January 1988, and August 1998 the Veteran denied "frequent trouble sleeping." Also, during the Veteran's February 2005 separation examination he also denied "frequent trouble sleeping." Post-service treatment records show the Veteran underwent a sleep study in August 2007 and was diagnosed with (1) obstructive sleep apnea syndrome, severe range, (2) split night study, and (3) insomnia, mood disorder, joint pain. The plan was for the Veteran to get as close to ideal body weight as possible, sleep in the lateral position, and start the CPAP (continuous positive airway pressure). The Veteran filed a claim for service connection for sleep apnea in November 2007. At that time the Veteran indicated that he was seeking service connection for a sleep disorder on a direct basis. Specifically, in January 2008 correspondence the Veteran reported that his sleeping problems began in 2004 (during military service) at which time he was given sample packages of Ambien by a physician's assistant. However, after the RO awarded service connection for PTSD in a March 2011 rating decision, the Veteran submitted correspondence in April 2012 claiming that his sleep disorder was secondary to PTSD. In June 2012, a VA examiner opined that the Veteran's sleep apnea (which was first diagnosed in August 2007) was not caused by or a result of his service-connected PTSD (which was first diagnosed in August 2008). The rationale for this opinion was that "sleep apnea is not caused by PTSD." Initially, the Board notes that while the June 2012 VA examiner opined that the Veteran's sleep apnea is not related to his PTSD, he did not address whether the Veteran had any other sleep disorder (other than sleep apnea) that could be related to his PTSD. Significantly, the examiner noted that the Veteran was on medications for his depression that can cause drowsiness. As noted above, in October 2013, the Board recharacterized the claim on appeal, and remanded the matter to obtain further VA medical opinion needed to resolve the claim. Specifically, the Board noted that the June 2012 VA examination raised a question as to whether the Veteran's sleep problems are related to medications he uses for his PTSD. In addition, an opinion was deemed necessary to address whether the Veteran's claimed sleep disorder was directly related to his military service. Pursuant to the Board's remand, the Veteran was afforded a VA examination in November 2013. The examiner reviewed the claims file and noted a diagnosis of obstructive sleep apnea. During this examination, the Veteran reported that back in 2003, when he was deployed, he began having trouble sleeping. He would wake up in the night. After he got home it got better. Then, in 2004, he was on his second deployment, and the problem started again. He was not sure it was the cot that he was sleeping on that was causing the insomnia. He reported that he spoke informally with a provider during the deployment who "gave me a few Ambien pills to try." He reportedly took Ambien for a few days which was not too much help so he decided not to take them anymore. He stated that he continued to have insomnia for the remainder of the nine month deployment. When he got home, his insomnia did not improve and he continued to awaken in the middle of the night. He then went to VA and reportedly informed his PCP (primary care practitioner) about his insomnia. He tried the OTC (over the counter) Sleep-eze which did not work. Then his PCP prescribed Trazodone which also did not help. On a subsequent visit to his PCP, he informed him about his snoring and gasping and was diagnosed with obstructive sleep apnea after having a sleep study. The Veteran reported that though he had used the CPAP for the past five years, he continued to have middle insomnia with at least two awakenings per night. He usually slept for a total of four hours per night on average. The examiner noted that the Veteran did not require continuous medication for control of his sleep disorder but that the did use a CPAP machine. The examiner also noted that the Veteran had persistent daytime hyper somnolence. The examiner related the findings of the September 2007 private sleep study which noted diagnoses of (1) obstructive sleep apnea syndrome, severe range, (2) split night study, and (3) insomnia, mood disorder, joint pain. The plan was for the Veteran to get as close to ideal body weight as possible, sleep in the lateral position, and start the CPAP. The examiner noted that the Veteran's BMI (body mass index) in 2007 was 28.4 which was in the overweight range but that his BMI was currently 30.2, which was in the obese range. The examiner indicated that the Veteran's sleep apnea did not impact his ability to work. The examiner provided the following medical opinions: 1. The claimed obstructive sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. 2. The claimed sleep disorder (insomnia) was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. 3. The claimed sleep disorder (insomnia) was less likely than not (less than 50 percent probability) caused or aggravated (i.e., worsened beyond normal progression) by the Veteran's service-connected PTSD, to include any medication(s) used to treat the disorder. The examiner reviewed the Veteran's service treatment records and noted the following: 1. There were no documented sick call visits for any sleep issues in the Veteran's [service treatment records] for his entire period of active duty military service (23 years). 2. A Post-Deployment Questionnaire completed by the Veteran [in December 2004] denied sleep problems. The Veteran specifically did NOT indicate that he "still felt tired after sleeping." 3. On Report of Medical History dated [in February 2005], the Veteran checked the "NO" box for "frequent trouble sleeping." 4. On the Veteran's Retirement Physical Examination dated [in February 2005], there was no noted complaint of insomnia or difficulty sleeping. A review of the Veteran's VA treatment records revealed the following: 1. When [the Veteran] had his initial appointment [in January 2006] when his VAMC (VA Medical Center) PCP, the Veteran did not report insomnia or any sleep issues. 2. The Veteran was diagnosed with insomnia [in January 2007] during his second appointment with his VAMC PCP. He was prescribed Trazodone PRN for his sleeping problem. 3. [In April 2007], the Veteran was started on Remeron for insomnia with possible anxiety and depression. 4. [In May 2007], it was noted that neither Trazodone nor Remeron were effective for the Veteran's insomnia. 5. [In July 2007], the [V]eteran was seen by Mental Health for his insomnia. The Veteran noted that he had been experiencing middle insomnia for the previous 4 years, and that his wife said that he snored loudly and "breathed hard." The Veteran reported feeling tired in the day time. He was referred for a sleep study. 6. The Veteran was diagnosed with severe obstructive sleep apnea [in September 2007] after undergoing a polysomnography at the Cape Fear Valley Sleep Center. He was prescribed [a] CPAP. 7. The Veteran initially reported difficulty with getting used to the CPAP, with only infrequent use of the device. 8. [In September 2009], he was noted to have low compliance with the CPAP machine, and was encouraged to wear the CPAP device more consistently. 9. [In April 2010], the Veteran continued to report a total sleep time of 4 hours/night, and denied nightmares. 10. He again noted only 4-5 hours of sleep per night [in July 2010]. 11. [In April 2012], the Veteran was again counseled to use his CPAP device more consistently. 12. [In March 2013], the Veteran reported that he felt that the benefits of the CPAP therapy outweighed the difficulties that he had with it. He denied no new issues or problems. 13. During the examination today, the Veteran stated that he has used the CPAP machine for the past 5 years with no resolution of his middle insomnia. He continues to report an average of 2 awakenings each night with 4 hours of total sleep. 14. Also during the examination today, the Veteran stated that in 2003 when he was deployed he began having trouble sleeping. He would wake up in the night. After he got home it got better. Then, in 2004 he went on a 2nd deployment, and the problem started again. He wasn't sure if it was the cot that he was sleeping on that was causing his insomnia. He reported that he spoke informally with a medical provider during the deployment who "gave him a few Ambien pills to try." He reportedly took the Ambien for a few days which wasn't too much help, and so he decided not to take them anymore. He stated that he continued to have insomnia for the remainder of the deployment (9 months). When he got home his insomnia did not improve and he continued to awaken in the middle of the night. The November 2013 VA examiner concluded that, although there is no documentation in the Veteran's service treatment records of any sleep disorder (either by the Veteran himself, or any medical provider), the examiner considered him to be a reliable historian with what appeared to be a clear memory of the onset of his sleep difficulties. It was the examiner's opinion that the Veteran suffered from middle insomnia, in addition to the obstructive sleep apnea (OSA) that was clearly diagnosed after his active duty military service. The examiner observed that, if primary sleep issue was due to the Veteran's OSA, one would reasonably assume that the prescribed treatment (a CPAP device) would provide some, if not complete relief of the condition. As per the Veteran's report during the examination, and also noted in his VA treatment record, he continued to experience middle insomnia with an average of 2 nighttime awakenings, despite the use of the CPAP device for the past 5 years. According to the examiner, this clearly indicated that the primary issue was not the OSA, but the Veteran's seemingly intractable insomnia. If, in fact, the Veteran's sleep issues were partially or completely resolved with the use of the CPAP device, the examiner indicated that she would be more inclined to state that he most likely had the OSA beginning in 2003 or 2004, with the onset of his insomnia. Since that is not the case, the examiner opined that the Veteran's insomnia had its inception in 2003 or 2004 during his active duty service, as reported by the Veteran. The Veteran had consistently described middle insomnia with an average of 2 nighttime awakenings, with a total sleep time of 4 hours per night. He had been receiving treatment for his PTSD with no worsening or improvement of his insomnia symptoms. Therefore, the examiner opined that neither the Veteran's PTSD diagnosis, nor the treatment for it has aggravated (i.e., worsened beyond normal progression) his insomnia. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107; Gilbert, supra. In light of the foregoing, the Board finds that pertinent lay and medical evidence of record collectively indicates that the Veteran has insomnia that was first manifested and treated during active service, and has continued to date. Accordingly, and with resolution of all reasonable doubt in the Veteran's favor, the criteria for service connection for insomnia are met. However, the Board also finds that the criteria for service connection for sleep apnea are not met. In this case, the Veteran has not specifically contended, and the evidence does not show, in-service complaints, findings, or diagnoses pertaining to sleep apnea. As above, service treatment records are negative for sleep problems and while the Veteran has competently reported "trouble sleeping" associated with insomnia beginning during military service, the first indication of sleep apnea is dated in a July 2007 VA treatment records when the Veteran reported that his wife said that he snored loudly and "breathed hard." Furthermore, there is no competent evidence or opinion supporting the Veteran's contention that his currently diagnosed sleep apnea is in any way related to his service. In fact, in the only competent opinion of record to address the question such question, the November 2013 VA examiner determined that the currently diagnosed sleep apnea was less likely than not related to the Veteran's service. As indicated, this opinion was based on both examination of the Veteran and review of the claims file, and the examiner provided a rationale for her conclusion. No contrary, competent evidence on the question of direct relationship to service has been presented or identified. Although the Veteran suggests that he has had "trouble sleeping" since service, and he is competent to report his symptoms, like other matters within his personal knowledge (see, e.g., Charles v. Principi, 16 Vet. App. 370 (2002)), he simply does have the medical training or expertise to competently attribute symptoms to a specific diagnosis, or to provide a probative opinion on the question of medical etiology. Matters of diagnosis and etiology of the complex disability here issue are based on internal processes not observable to the human eye; hence, questions of diagnosis and etiology of such disabilities are only within the province of individuals with special knowledge, training, and experience. See Kahana, 24 Vet. App. at 438; Davidson, 581 F.3d at 1316. As the Veteran is simply not shown to have such special knowledge, training, and experience, his assertions as to matters of diagnosis or medical etiology in this appeal have no probative value. Thus, the Board finds that the only competent, probative opinion to address the relationship, if any, between current sleep apnea and service weighs against this aspect of the claim. See e.g., Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)) (holding that the weight to be attached to medical opinions is within the province of the Board). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). Significantly, in this case, the VA examiner considered the Veteran's assertions as to continuity of symptoms, and still rendered an opinion that weighs against a finding of direct service connection. Likewise, there is no competent evidence or opinion supporting the Veteran's contention that his currently diagnosed sleep apnea is medically related to his service-connected PTSD. In fact, in the only competent opinion of record to address the question of etiology of the sleep apnea on a secondary basis, the June 2012 VA examiner determined that the Veteran's PTSD was not in any way related to his service-connected PTSD. As indicated, this opinion was based on both examination of the Veteran and review of the claims file, and the examiner provided a rationale for her conclusion; accordingly, the Board accepts this opinion as probative of the secondary service connection question. Significantly, there is no contrary, competent evidence or opinion even suggesting a secondary relationship-on the basis of causation or aggravation-and, again, for the reasons set forth above, the Veteran is not competent to provide a probative etiology opinion on the basis of his own lay assertions. Thus, the Board finds that the only competent, probative opinion on the question of secondary service connection also weighs against this aspect of the claim. For all the foregoing reasons, the Board finds that, while the record presents a basis to award service connection for insomnia, service connection for sleep apnea must be denied. The Board has favorably resolved reasonable doubt in the Veteran's favor to award service connection for insomnia, but finds that the preponderance of the evidence weights against awarding service connection for sleep apnea, to include on a secondary basis. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for insomnia is granted. Service connection for sleep apnea, to include as secondary to PTSD, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs