Citation Nr: 1433652 Decision Date: 07/28/14 Archive Date: 08/04/14 DOCKET NO. 08-29 035 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for hepatitis C. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from April to August 1969. This matter initially came before the Board of Veterans' Appeals (Board) from an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In that decision, the RO denied the Veteran's petition to reopen a claim of service connection for hepatitis C as new and material evidence had not been submitted. The Veteran testified before the undersigned at a January 2011 hearing at the RO (Travel Board hearing). A transcript of that hearing has been associated with the record. In April 2011, the Board granted the petition to reopen the claim of service connection for hepatitis C and remanded the underlying claim for further development. In April 2012, the Board issued a decision that denied the appealed claim of service connection for hepatitis C. Pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F. 3d 1312 (Fed. Cir. 2013), the Board's April 2012 decision was identified as having been potentially affected by an invalidated rule relating to the duties of the Veterans Law Judge that conducted the January 2011 hearing. In order to remedy any such potential error, the Board sent the Veteran a letter in September 2013 notifying him of an opportunity to receive a new hearing and/or a new decision from the Board. Subsequently, the Veteran requested only to have the prior decision vacated and a new one issued in its place. Hence, the April 2012 decision was vacated by the Board in March 2014 and this decision satisfies the Veteran's request. In April 2014, the Board remanded this matter for further development. This appeal was processed using the Veteran's Benefits Management System (VBMS) and the Virtual VA claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. FINDING OF FACT Hepatitis C did not have its clinical onset in service and is not otherwise related to active duty. CONCLUSION OF LAW Hepatitis C was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION 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, 5126 (West 2002 & Supp. 2013) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in April 2007, the RO notified the Veteran of the evidence needed to substantiate his claim of service connection for hepatitis C. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claim, in the April 2007 letter. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2013) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's January 2011 hearing, the undersigned identified the issues on appeal at that time (including whether new and material evidence had been submitted to reopen the claim of service connection for hepatitis C) and notified the Veteran of the evidence necessary to substantiate his underlying claim of service connection for hepatitis C. Also, the Veteran provided testimony as the history and treatment of his hepatitis C and his possible risk factors and he has submitted additional evidence during the course of the appeal. Thus, he has demonstrated actual knowledge of the ability to identify and submit additional relevant evidence. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records and all of the identified relevant post-service VA treatment records. He has not reported, and the evidence does otherwise indicate, that he has received any relevant post-service private medical treatment for hepatitis C. In addition, the Veteran was afforded a VA examination to assess the etiology of his claimed hepatitis C and an opinion has been obtained concerning the etiology of this disability. In its April 2011 and April 2014 remands, the Board instructed the agency of original jurisdiction (AOJ) to, among other things, attempt to obtain any available Social Security Administration (SSA) disability records; obtain all relevant VA treatment records contained in the San Diego Visa electronic records system and dated from September 2005 through March 2007, from August 2008 through October 2013, and from March 2014 through the present; and schedule the Veteran for a VA examination to obtain an opinion as to the etiology of his hepatitis C. As explained above, all relevant VA treatment records have been obtained and associated with the Veteran's paperless records (including records contained in the San Diego Visa electronic records system and dated from September 2005 through March 2007, from August 2008 through October 2013, and from March 2014 through the present). Also, a VA examination was conducted in May 2011 and an opinion was obtained as to the etiology of the Veteran's hepatitis C. The AOJ contacted the SSA in May 2014 and requested all available records pertaining to any claim for supplemental security income or disability benefits submitted by the Veteran. The SSA responded that no records could be sent and that further efforts to obtain any such records would be futile because the Veteran's medical records had been destroyed. In a May 2014 letter, the Veteran was notified of the unavailability of SSA records and of the efforts that had been taken to obtain such records, he was asked to submit any such records in his possession, and he was notified that his claim could be decided within 10 days if no further evidence was received. He did not respond to the May 2014 letter. Thus, the AOJ determined that any further efforts to obtain SSA disability records would be futile and VA has no further duty to assist in obtaining any available SSA disability records. 38 C.F.R. § 3.159(c)(1). Therefore, the AOJ substantially complied with all of the Board's pertinent April 2011 and April 2014 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claim being decided herein. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires (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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran asserts that hepatitis C was incurred during active service. In written statements and oral testimony, including before the Board in January 2011, he contends that he was exposed to blood from the medical shots given and needle used during processing in service. He has also variously asserted that his hepatitis C developed from blood to which he was exposed during daily practice sessions with pugil sticks against other servicemen, over a two to three week period, because the practice led to both individuals suffering cuts during the exercises. He claimed to have cut his finger in service, may have had a blood transfusion and shared razors. Thus, he maintains that service connection is warranted for hepatitis C. However, although the evidence shows that the Veteran currently has hepatitis C, no competent evidence has been submitted to show that this disability is related to service or any incident therein. The Veteran maintains that service connection is warranted for hepatitis C. After carefully considering the claim in light of the record and the applicable law, the Board finds that the preponderance of the evidence of record is against the claim, and his appeal will be denied. Prior to entering service, private medical records indicate that, in November 1968, the Veteran was hospitalized for treatment of multiple cuts and abrasions after a fall through a glass door. During his hospital course, records show that his wounds were all closed primarily; the profundus tendon of the left fourth finger was picked up and sutured, securing it at the base of the proximal phalanx on the volar surface with wires carried through the fingers and secured on the dorsal aspect of the nail over a button. Post operatively, there was no evidence of any localized or systemic infections, or of any inflammatory changes; dressings were changed, and his wounds looked good. The Veteran's service treatment records are not referable to any complaints or findings of, or treatment for, hepatitis C. A May 1969 clinical record describes old injuries to both ring fingers within the past ten months; the Veteran's right ring finger had laceration of the palmar surface at the level of the metacarpophalangeal joint. An August 1969 Medical Board Report indicates that the Veteran gave a history of an incomplete amputation of the base of his right ringer finger at age eleven. The wound healed with lack of any flexor function of the ring finger. He was advised to undergo surgery for tendon repair but it was not done. Post service, VA treatment records reveal findings of hepatitis C in May 2000. At that time, he was asked to identify possible risk factors for exposure. Results of an ultrasound examination of the Veteran's liver performed in July 2000 were normal. An April 24, 2001 VA medical record reflects a number of post-service risk factors for hepatitis C, including that the Veteran reported that, in the 1970s, he fell through plate glass, and required a transfusion of four to five pints of blood. He also noted that he may have been exposed to blood through teaching the air conditioning business, in showing students how to do the work, where both he and the students suffered cuts, from 1992 to 1993. The VA practitioner also noted additional risk factors of the Veteran's status as a Vietnam era vet and because of multiple sexual partners (although the Veteran testified that he was careful, and his three wives were never diagnosed with the disease). An April 25, 2001 VA outpatient psychiatry note indicates that the source of the Veteran's hepatitis C was unknown. It was noted that he had a blood transfusion in 1967/1968 at the University of California in San Diego that may be the source of his hepatitis C. VA treatment records, dated in May 2001, identified the following risk factors for transmission of the Veteran's virus: blood transfusion in the 1970s, 4 to 5 units, after falling through plate glass; multiple sexual partners; Vietnam-era veteran; and exposure to blood through teaching air conditioning, and having cuts and students with cuts in sheet metal work, in 1992 and 1993. A November 2002 VA medical record shows that the Veteran reviewed his operation records (apparently from 1968) and did not have a transfusion. In December 2002, the Veteran asserted that his hepatitis C resulted from the shots given and needle used during processing in service. In a May 2003 written statement, the Veteran reported that his hepatitis C "probably" resulted from blood transfusion in military service. In May 2005, he testified that he believed his hepatitis C developed from the way medical shots were administered with an injection gun in service; and that a lot of people were bleeding. He testified that he had no other blood transfusions, or risk factors for hepatitis C. A July 2005 VA examination report includes a diagnosis of hepatitis C untreated with no apparent complication. In a March 2007 written statement, the Veteran said that he never had an organ transplant, never had a transfusion that he knew of; and never had hemodialysis. He claimed exposure to blood in boot camp from immunization shots. The Veteran indicated that he never indulged in any drug use, never had high risk sexual activity; and never shared articles listed (toothbrushes or shaving razors). In an April 2007 signed statement, Dr. C.P., a VA staff physician who treated the Veteran, noted that he had few of the traditional risk factors for hepatitis C and reported getting immunized during service with a gun used on multiple people. Dr. C.P. said that "if [the Veteran] was immunized with a medical device that had been used on other people and could have been contaminated, this could most certainly be how he was exposed to hepatitis C." In May 2007, the Veteran submitted a 1969 Marine book of photographs that revealed use, at that time, of an injector gun in medical examinations. A July 2007 VA examination report includes the Veteran's history of injuring his right ring finger at age 11. He had a superficial wound that did not require operative intervention. The Veteran had a second injury to his upper extremities in 1969 and was seen at the University Hospital in San Diego in November 1968, as noted above. He had two superficial lacerations of the right forearm, multiple lacerations of the left hand, but no significant lacerations of the right hand. The VA examiner noted that the Veteran experienced an incomplete amputation of the left ring finger, not the right one as some medical records incorrectly noted. During his January 2011 Board hearing, the Veteran testified that he was exposed to blood from the medical shots given and needle used during processing in service. He testified that shots were administered with an injector gun, and that a lot of people were bleeding. He denied intravenous drug use and having multiple sexual partners, but indicated that he had three wives, none of whom had hepatitis C. The Veteran indicated that he did not know whether he received a blood transfusion for his finger operation. In May 2011, the Veteran underwent a VA examination. The examiner noted a review of the Veteran's medical records and performed a clinical evaluation. It was noted that the Veteran provided a "graphic" description of his weeks in boot camp prior to his injury and referenced vaccinations with the "blood flying all over, with multiple sharing of razors and toothbrushes, and training with [pugil] sticks." As to the April 2007 VA staff physician's statement, the VA examiner observed that there were "a lot of [ifs] and [coulds] in [her] letter. It is understood that [the letter] was written as a direct request by a patient to a treating physician who has a very vested responsibility in that patient's equanimity." The VA examiner commented that the Veteran's impression of the immunization machine used was that it had a needle that was dripping with blood and was used in patient after patient. The VA examiner said that the Veteran's description to the VA staff physician, the Board, and the examiner, certainly differed significantly from the same vaccination apparatus that was used on the VA examiner and the examiner's other comrades in arms who were reluctantly deployed to Vietnam in 1969-70. The air-injection apparatus that was employed with vaccinations "could" always have a remote possibility of some minute contamination. Transfer of blood between patients or service members with this apparatus had not been documented, nor had there been a report for confirmation of hepatitis C cluster among service members associated with boot camp. The exceptions were for service members who shared needles for drug usage, had a common contaminated tattoo source, or were in a very high risk and active sexual grouping. There was no cluster of hepatitis contaminees among the groups that the Veteran sought to blame. The VA examiner then noted that, in several areas of the record, the Veteran had documented exposures to blood under circumstances that were of higher risk than that he referenced. The first was when the Veteran was a youth at age 11 in Oakland, California, and got a pretty good slice injury to his right hand. The second incident occurred in 1968 in San Diego when the Veteran put his left hand and right forearm through a glass door, had a perfusion of blood loss and had to be sewn up at the University of California, San Diego, emergency room. Although the VA examiner did not have the details from these episodes, he said that his experience with similar episodes and long experience with vaccination clinics as well as the rigors that one is put through in boot camp led him to think that those episodes and other unaddressed issues were much more suspect than exposures during boot camp. Further, it was noted that the Veteran was released from active service due to a right ring finger flexor tendon injury. Hepatitis C was initially diagnosed in the late 1990s and, in 2001, tests showed hepatitis B and C. The VA examiner said that, while the Veteran's description of his current symptoms included fevers, chills and fatigue, that was inconsistent with the histories and physicals of his medical treatment health care professionals. It was also not consistent with his vital signs, weight, and serum chemistries. The VA examiner commented that it was a bit difficult to get an accurate picture. The Veteran believed he was exposed to hepatitis C by "all the blood" that was around during immunizations or the sharing of razors and toothbrushes. He denied use of intravenous drugs and high risk sexual activity. The diagnosis was hepatitis C, serologically positive without any evidence of advanced cirrhosis at the present time. In the VA examiner's opinion, it was less likely than so that the "EEG elegy" or cause of the Veteran's hepatitis C occurred while he was in service, that the original exposure to the infectious virus was in the service, or that it was related to active service or active service related injuries. The VA examiner noted his consideration of the Veteran's opinion, a thorough review of the records, the supporting data, and the examiner's 43 years of medical practice, as well as membership in the U.S. military and association with training, vaccination, and treating facilities as an active health care practitioner from 1969 to 2003. In a November 2011 signed statement, the Veteran said that his right ring finger injury was an open wound injury in service that was only bandaged and never properly treated. His 1973 surgery was to repair the damage and "could" have been the cause of his being exposed to hepatitis C. He also said that the statement of using other people's toothbrushes was incorrect. He submitted copies of three prior Board decisions that granted service connection for hepatitis C related to air gun injector inoculations based upon etiological opinions that supported those claims. Here, the service treatment records do not provide evidence of a chronic hepatitis C disorder in service. When the Veteran was evaluated prior to separation in August 1969, no problems with hepatitis C were identified. The record unequivocally shows that there was no medical evidence of hepatitis C, or any other diagnosed blood or liver disability, for many years after service. The first documented evidence of any type of hepatitis C problem after service is from the VA records dated in 2000, more than 30 years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (to the effect that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). In short, no medical opinion or other medical evidence relating the Veteran's hepatitis C disorder to service or any incident of service has been presented. The most probative opinion of record is that of the May 2011 VA examiner who opined that that it was less likely than so that the "EEG elegy" or cause of the Veteran's hepatitis C occurred while he was in service. According to the VA examiner, it was much less likely than so that the clinical onset of the hepatitis C was in service, that the original exposure to the infectious virus was in service, or that it was related to active service or active service related injuries. The VA examiner provided a clear rationale to support that opinion. There is no competent evidence to contradict this opinion. In support of the claim, an April 2007 statement from Dr. C. P., the Veteran's treating VA staff physician, reflects that if the Veteran was immunized with a medical device that had been used on other people and could have been contaminated, this could most certainly be how he was exposed to hepatitis C. This fact is also supported by etiology opinions cited in copies of Board decisions submitted by the Veteran. The possibility of a connection is not disputed or that other Veteran's may have been contaminated by in-service inoculations. The Board must determine if there is at least a 50 percent probability that that hepatitis C was due to inoculations of the Veteran in service or is otherwise related to active duty. Since the VA examiner's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the Veteran's claim. The Board emphasizes that the VA examiner provided a valid medical analysis to the significant facts of this case in reaching his conclusion. In other words, the VA examiner did not only provide data and conclusions, but also provided a clear and reasoned analysis that the Court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); see also Wray v. Brown, 7 Vet. App. at 493. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VA examiner who provided the written opinion in May 2011. This medical specialist, who has 43 years of medical training, had the opportunity to review all the Veteran's medical records regarding the diagnosis of hepatitis C. This VA examiner said that the Veteran's impression of the immunization machine used was that it had a needle that was dripping with blood and was used in patient after patient, but the VA examiner indicated that the Veteran's description to the VA staff physician, the Board, and the examiner differed significantly from the same vaccination apparatus that was used on the VA examiner and his comrades who were deployed to Vietnam in 1969-70. The VA examiner said that the air-injection apparatus that was employed with vaccinations could always have a remote possibility of some minute contamination. The VA examiner also noted that, in several areas of the record, the Veteran had documented exposures to blood under circumstances that were of higher risk than that he referenced, including at age 11 when he injured his right hand, and in 1968 when the Veteran put his left hand and right forearm through a glass door, had a perfusion of blood loss and had to be sewn up at the University of California, San Diego, emergency room. Although the VA examiner did not have the details from these episodes, he said that his experience with similar episodes and long experience with vaccination clinics as well as the rigors that one is put through in boot camp led him to think that those episodes and other unaddressed issues were much more suspect than exposures during boot camp. This physician explained that the Veteran's hepatitis C was diagnosed in the 1990s, that there were at least two pre-service accidents during which the Veteran could have been exposed to hepatitis C, and that the Veteran's current hepatitis C was not related to military service. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). As to the April 2007 opinion of Dr. C.P., the VA clinic physician, who opined that the if the Veteran was immunized with a medical device that was used on other people and could have been contaminated, this could most certainly be how he was exposed to hepatitis C, the Board finds that, given the scope and depth of the VA examiner's expertise and rationale, his opinion carries more weight than that of Dr. C.P. The Board is persuaded that the VA examiner's opinion is most persuasive in that this physician reviewed all the Veteran's medical records and provided a rationale for his opinion. See Prejean v. West, Wray v. Brown, supra. The Veteran is competent to discuss risk factors of hepatitis he encountered. In May 2005 testimony, the Veteran asserted that his hepatitis C developed from the way medical shots were administered with an injection gun, and that a lot of people were bleeding. The VA examiner noted that the Veteran's description "differs significantly" from the apparatus used on the examiner. The examiner said that the air gun injection apparatus could always have a remote possibility of some minute contamination, but transfer of blood between patients or service members with the apparatus was not documented. This examiner also stated that there has not been a report for confirmation of hepatitis C cluster among service members associated with boot camp, aside from service members who shared needles for drug use, had a common contaminated tattoo source, or engaged in high risk sexual behavior. The Veteran's descriptions of risk factors have also changed over the years, differing significantly now than when he was first diagnosed. His descriptions of significant injuries, blood transfusions outside of service and several cuts as a student and while working have been minimized by him or left out altogether in recent histories. He is not shown to be a consistent or reliable historian. The Veteran has expressed his belief that his hepatitis C is related to various risk factors in service. However, as a lay person, he can only comment as to symptoms and immediately-observable relationships. He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his current hepatitis C is related to any specific risk factor in service, as opposed to some other cause. Rather, it would require medical expertise to evaluate the disability, consider all the potential causes, and determine that one was a more likely cause than another. Hence, the Veteran's opinion on this question is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2) (2013). The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance of the evidence of record is against the Veteran's claim of service connection for hepatitis C, and his claim must be denied. ORDER Entitlement to service connection for hepatitis C is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs