Citation Nr: 0411586 Decision Date: 05/04/04 Archive Date: 05/14/04 DOCKET NO. 02-16 260 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for diabetes mellitus. 2. Entitlement to compensation under 38 U.S.C.A. § 1151 for hypercholesterolemia. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 for hypokalemia. 4. Entitlement to compensation under 38 U.S.C.A. § 1151 for diverticulosis. 5. Entitlement to compensation under 38 U.S.C.A. § 1151 for hypothyroidism. 6. Entitlement to compensation under 38 U.S.C.A. § 1151 for depression. 7. Entitlement to compensation under 38 U.S.C.A. § 1151 for hypertension. 8. Entitlement to compensation under 38 U.S.C.A. § 1151 for kidney disease. 9. Entitlement to an increased rating for pancreatitis, currently assigned a 10 percent evaluation. 10. Entitlement to a total disability rating based on individual unemployability (TDIU rating). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The veteran had active service from May 1957 to July 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an RO rating decision of September 2001, which denied a higher rating for pancreatitis and a total disability rating based on individual unemployability (TDIU rating). The rating decision also denied service connection for diabetes mellitus, hypercholesterolemia, hypokalemia, diverticulosis, hypothyroidism, depression, hypertension, and kidney disease. However, although the veteran referred to service connection in her claim, she contends that these disabilities are due to the pancreatitis for which she is in receipt of compensation under 38 U.S.C.A. § 1151, and the issues have been framed to reflect the correct basis of the claim. Because the claims have been addressed by both the RO and the veteran in the context of whether they resulted from the VA surgery and/or ensuing pancreatitis, she is not prejudiced by our deciding the case at this time on the merits. See Bernard v. Brown, 4 Vet.App. 384 (1993). In the October 1998 rating decision which granted compensation under 38 U.S.C.A. § 1151 for pancreatitis, the RO assigned an effective date in January 1998, based on the date of claim. However, the correct effective date for benefits based on 38 U.S.C.A. § 1151 is the date the injury or aggravation occurred if a claim is received within one year. 38 U.S.C.A. § 5110(c); 38 C.F.R. § 3.400(i). In this case, the injury occurred in September 1997 and the claim was received in January 1998, within a year of the injury. However, the effective date issue is not currently before the Board, and the matter is referred to the RO for appropriate action. As will be discussed in the remand section at the end of the present Board decision, issues numbered 7 through 10 on the title page are being remanded to the RO via the Appeals Management Center (AMC) in Washington, D.C. As to those issues, the VA will notify the veteran if further action is required. FINDINGS OF FACT 1. Diabetes mellitus increased in severity as a result of pancreatitis suffered in September 1997. 2. Hypercholesterolemia and depression, if present, pre- existed the September 1997 VA hospitalization, and did not increase in severity as a result of pancreatitis. 3. Hypokalemia and diverticulitis are not currently shown. 4. Hypothyroidism was not caused or worsened by pancreatitis. CONCLUSIONS OF LAW 1. A portion of the veteran's current diabetes mellitus is proximately due to or the result of pancreatitis. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.310 (2003). 2. Hypercholesterolemia, hypokalemia, diverticulosis, hypothyroidism, and depression are not proximately due to or the result of pancreatitis. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.310 (2003). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. General Background The veteran had active service from May 1957 to July 1958. In September 1997, the veteran was hospitalized in a VA facility for an endoscopic retrograde cholangiopancreatography (ERCP) due to a suspected pancreatic abnormality on a computerized tomography (CT) scan. The examination was negative. However, the veteran developed post-ERCP acute pancreatitis with pseudocysts, and numerous complications including pneumonia and sepsis. She was transferred to Vanderbilt University Hospital in September 1997, where she remained hospitalized until December 1997 for treatment of pancreatitis and complications. In a rating decision dated in October 1998, she was granted compensation under 38 U.S.C.A. § 1151 for pancreatitis, assigned a 10 percent rating. In January 2001, she submitted a claim for an increased rating for pancreatitis, and also claimed compensation for diabetes mellitus, hypercholesterolemia, hypokalemia, diverticulosis, hypothyroidism, depression, hypertension, and kidney disease, all as a result of the ERCP procedure in September 1997. She also said she had not worked since the procedure and submitted a formal TDIU claim in March 2001. Through correspondence, the rating decision, and the statement of the case, the veteran has been informed of the evidence necessary to substantiate her claims addressed in the main portion of the Board decision. As to those issues, identified relevant medical records have been obtained, and additional VA examinations are not necessary to decide the claims. The Board finds that the notice and duty to assist provisions of the law have been satisfied as to these issues. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The current version of the law provides, in pertinent part, that compensation shall be awarded for a qualifying additional disability of a veteran in the same manner as if the additional disability were service connected. A disability is considered a qualifying additional disability under the law if it is not the result of the veteran's own willful misconduct and the disability was caused by VA hospital care, medical or surgical treatment, or examination, and the proximate cause of the disability was: 1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination; or 2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151 (West 2002). Disability compensation may be paid, pursuant to 38 U.S.C. § 1151 and 38 C.F.R. § 3.310, for disability which is proximately due to or the result of a disability for which compensation is payable under section 1151. VAOPGCPREC 8-97; see also Allen v. Brown, 7 Vet.App. 439 (1995). The general counsel opinion specifically states that the new amendments to 38 U.S.C.A. § 1151, effective in October 1997, would not affect the analysis in the opinion. VAOPGCPREC 8-97. II. Individual issues A. Diabetes mellitus VA medical records dated from 1989 to 1992 show the presence of diabetes mellitus beginning in 1992. VA records dated from 1995 to 1996 show her continued treatment for non- insulin dependent diabetes mellitus (NIDDM). When admitted to the VA hospital in September 1997, a history of Type II diabetes mellitus for 5 years was noted. Her blood glucose level shortly after admission was 326, with a normal range of 75 to 110. According to the discharge summary from Vanderbilt Hospital dated in December 1997, the veteran had previously been on an oral hypoglycemic agent for her diabetes mellitus, but had now been started on insulin, which was to continue after her discharge. On a VA examination of October 1998, it was noted that her diabetes had worsened after the pancreatitis, and now required insulin. Previously, it had been controlled with oral hypoglycemic agents. R. Hood, M.D., wrote, in a letter dated in December 1999, that the veteran had had fairly mild diabetes for a number of years until she developed an episode of pancreatitis in 1997, which accelerated her diabetes. On a VA examination in April 2001, the examiner noted that there was no clear link between the veteran's various maladies and pancreatitis. The onset of her diabetes had been before the pancreatitis, and while it was theoretically feasible that significant pancreatic injury could worsen glucose metabolism, there was no evidence for this having happened. However, the Board notes that while her diabetes mellitus was managed with oral medication before the pancreatitis, since then, she has required insulin, evidence of worsening glucose metabolism. Moreover, the previous VA examination in October 1998, as well as Dr. Hood's December 1999 letter, indicated that her diabetes mellitus had increased in severity as a result of the severe pancreatitis in 1997. In view of these factors, the Board finds that compensation under 38 U.S.C.A. § 1151 for diabetes mellitus, on the basis of aggravation, is warranted. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.310; VAOPGCPREC 8-97; Allen, supra. Thus compensation for diabetes mellitus as if service-connected is granted. The benefit of the doubt has been applied in making this decision. 38 U.S.C.A. § 5107(b). B. Hypercholesterolemia; hypokalemia According to a clinical history provided in connection with a pathology report of a specimen obtained from a renal biopsy in April 1995, the veteran had high cholesterol of 300. At the time of the September 1997 admission to a VA hospital, her cholesterol was 261. Three days later, her cholesterol was 128, and numerous other cholesterol levels obtained during that hospitalization and the succeeding hospitalization in Vanderbilt showed cholesterol levels of less than 200. Numerous blood potassium levels were obtained during the VA hospitalization in September 1997. Most of the findings were within the normal range of 3.6 to 5; however, on several occasions, low levels ranging from 2.8 to 3.4 were obtained, and on at least one occasion, the potassium level was elevated, to 5.3. When initially seen by W. Maynard, M.D., in January 1998, the veteran said that she had had cholesterol levels of 256 in the past, and the problem list at that time included hypercholesterolemia. In his March 1998 letter, Dr. Maynard wrote that the veteran's findings included severe hypercholesterolemia, and renal insufficiency with abnormal creatinine, albumin, and hypokalemia. Diagnoses included hypercholesterolemia and renal disease, but not hypokalemia. Subsequent records do not show the presence of hypercholesterolemia or hypokalemia, except by history, although on the October 1998 VA examination, the veteran said she was taking medication for her hypercholesterolemia. In general, abnormal laboratory findings reflect symptoms, rather than disabilities, and the hypokalemia noted in March 1998 was described as a symptom of renal disease, rather than a separate disease entity. Further, as early as 1995, well below the pancreatitis episode, the veteran's cholesterol was noted to be 300, and no higher level has since been shown. Additionally, neither hypercholesterolemia nor hypokalemia has been specifically associated with the pancreatitis, according to the medical evidence. Moreover, records after 1998 do not show the current presence of hypokalemia. Hypercholesterolemia has similarly not been shown, although there is evidence that she is taking medication for her cholesterol. Thus, hypercholesterolemia, if present, is not shown to be a separate disability; high cholesterol was shown well before the September 1997 hospitalization; and there is no specific evidence of an increase in severity of hypercholesterolemia during the hospitalization, or as a result thereof. For these reasons, compensation for hypercholesterolemia is not warranted. Hypokalemia is not shown to have been a separate disability, nor is it shown to be currently present. Without a disability, there can be no entitlement to compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997). The weight of the credible evidence establishes that the veteran's hypercholesterolemia and hypokalemia were laboratory findings, and not separate disabilities, and not caused or aggravated by pancreatitis. As the preponderance of the evidence is against the claim for compensation, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). C. Diverticulosis A computerized tomography (CT) scan of the abdomen in August 1997 was suggestive of a bladder diverticulum. Records of the September 1997 VA hospitalization, the Vanderbilt hospitalization from September 1997 to December 1997, and private outpatient treatment records dated from 1998 to 2000 make several references to a history of diverticulitis. On the VA examination in October 1998, the veteran said that she had undergone a colonoscopy the previous month, and that no lesions had been found. On the VA examination in April 2001, her prior history was noted to include diverticulosis which had been incidentally noted on colonoscopy. The examiner noted that there was no link between her pancreatitis and any colon condition. This medical evidence, which shows a history of diverticulitis reported during the September 1997 hospitalization, with no active findings shown at that time or subsequently, does not show the current presence of diverticulosis. Without a disability, there can be no entitlement to compensation. See Degmetich, supra. Moreover, the VA examination in April 2001 found that there was no link between diverticulosis and pancreatitis, and the evidence does not otherwise suggest a causal connection to the September 1997 hospitalization. The weight of the credible evidence establishes that diverticulosis was not caused or aggravated by pancreatitis. As the preponderance of the evidence is against the claim for compensation, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. D. Hypothyroidism VA medical records dated from 1989 to 1992 show that when initially seen in October 1989, the veteran was noted to have been taking Synthroid for two years, but from her history, it was thought that the medication had been started under questionable circumstances. She said she now had been feeling hot, sweaty, nervous, and jumpy. Her reflexes were brisk. Her thyroid medication was discontinued, and her thyroid levels were followed for several months. In March 1990, her thyroid function tests were normal, she was clinically euthyroid, and she was discontinued from the endocrinology clinic. No mention of a thyroid condition, either past or present, was noted in the summary of the September 1997 VA hospitalization. During the Vanderbilt hospitalization from September to December 1997, the veteran was discovered to be hypothyroid, and medication was begun, and Dr. Maynard's records dated from 1998 to 2000 continue to show medication for her thyroid condition. In his December 1999 letter, Dr. Hood wrote that the veteran's diabetes mellitus and other multiple medical problems were accelerated by the pancreatitis. However, on the VA examination in April 2001, the examiner specifically noted that there was no link between the pancreatitis and her thyroid condition. This explicit mention of the thyroid condition in the opinion carries more weight than the general reference to other medical conditions. Thus, the weight of the evidence shows that her thyroid condition was not caused or aggravated by the pancreatitis. As the preponderance of the evidence is against the claim for compensation, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. E. Depression VA medical records dated from 1989 to 1992 show that in December 1989, the veteran was noted to be nervous, with crying spells, and was to be referred to a psychiatric consultation for depression. At the time of admission to the VA hospital in September 1997, a history of depression requiring hospitalization in 1992 was noted, and this history has been reported on numerous other occasions. In February 1998, Dr. Maynard noted that she appeared somewhat depressed, and the assessment and plan included a question of depression, to be followed closely. However, the remaining records do not show a current diagnosis of depression, although a history of depression was noted from time to time. Moreover, the history refers to a hospitalization for depression in 1992, and there is no medical evidence of depression associated with the pancreatitis or otherwise with the September 1997 hospitalization. Additionally, because there is no current diagnosis of depression, or a link between a history of depression and the 1997 pancreatitis, it is not necessary to obtain the report of the 1992 hospitalization. The weight of the evidence shows that depression was not caused or aggravated by the pancreatitis. As the preponderance of the evidence is against the claim for compensation, the benefit- of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 for diabetes mellitus is granted. Entitlement to compensation under 38 U.S.C.A. § 1151 for hypercholesterolemia, hypokalemia, diverticulosis, hypothyroidism, and depression is denied. REMAND With respect to the remaining issues, the veteran contends that she has kidney disease resulting from the ERCP procedure. The RO developed this issue as whether new and material evidence has been received to reopen a claim for service connection for kidney disease; however, the previous RO decision, in June 1996, addressed service connection for kidney disease, whereas the veteran currently claims entitlement based on the September 1997 surgery and resulting pancreatitis. As such, it is a new claim under 38 U.S.C.A. § 1151, and must be decided on a de novo basis. Additional development of the evidence should be undertaken prior to a decision on the issues of compensation for hypertension and kidney disease, an increased rating for pancreatitis, and a TDIU rating. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Specifically, an examination should be conducted which specifically identifies the symptoms of pancreatitis. In addition, although the veteran clearly had hypertension and kidney disease prior to the episode of pancreatitis in 1997, during the September 1997 hospitalization she was also noted to have hypertensive urgency, and the discharge summary noted that the difficulty in controlling her blood pressure was thought to be due to her agitation and pain. Whether this resulted in a permanent increase in the severity of her hypertension is not shown. Likewise, the evidence does not show whether her kidney disease increased in severity as a result of the pancreatitis in 1997. In this regard, subsequent to that event, she her kidney disease progressed to the extent where dialysis and eventually a kidney transplant were required. Neither Dr. Hood's December 1999 letter nor the April 2001 VA examination address this matter with adequate specificity. See 8 U.S.C.A. § 1151; 38 C.F.R. § 3.310; VAOPGCPREC 8-97; Allen, supra. As a result, updated service treatment records should be obtained, and VA examinations with a medical opinion should be provided. Accordingly, the remaining issues are remanded for the following action: 1. The RO should ask the veteran to identify any records of treatment (not previously submitted) for kidney disease and/or hypertension from February 1996 to September 1997, and for kidney disease, hypertension, and pancreatitis from September 2000 to the present. The RO should then obtain copies of the related medical records. 2. The veteran should then undergo a VA examination by the appropriate specialist to determine the severity of pancreatitis. All symptoms specifically associated with this disease should be specifically identified. The claims folder must be provided to and reviewed by the examiner. The examiner should also identify which symptoms noted in the outpatient records dated from January 2000 to the present are associated with pancreatitis. 3. The RO should also have the veteran undergo a VA examination by the appropriate specialist to determine whether hypertension and/or kidney diseases increased in severity as a result of the September 1997 episode of severe pancreatitis. The claims folder must be provided to and reviewed by the doctor. Based on examination findings, review of historical records, and medical principles, the examiner should provide a medical opinion, with adequate rationale, as to whether an increase in severity occurred, with a discussion as to whether the hypertensive urgency noted in September 1997 resulted n a permanent increase in severity of hypertension, and whether the progression of kidney disease which occurred after the September 1997 hospitalization was wholly or partially due to the September 1997 episode of pancreatitis. 4. After assuring compliance with the notice and duty to assist provisions of the law, the RO should readjudicate the claims for compensation under 38 U.S.C.A. § 1151 for hypertension and kidney disease, an increased rating for pancreatitis, and a TDIU rating. If the claims remain denied, the RO should provide the veteran and her representative with a supplemental statement of the case, and give them an opportunity to respond, before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ L. W. TOBIN 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