Citation Nr: 0811671 Decision Date: 04/09/08 Archive Date: 04/23/08 DOCKET NO. 05-06 110 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for post-traumatic stress disorder.Entitlement to service connection for chloracne. 2. Entitlement to a compensable rating for bilateral hearing loss 3. Entitlement to service connection for chloracne. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Veteran and A. C. ATTORNEY FOR THE BOARD Motrya Mac, Associate Counsel INTRODUCTION The veteran, who is the appellant, served on active duty from February 1968 to December 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions, dated in June 2004, January 2005 and September 2005, of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In February 2008, the veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. FINDINGS OF FACT 1. Under the General Rating Formula for Mental Disorders, post -traumatic stress disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of the inability to perform occupational tasks, but does not produce occupational and social impairment with reduced reliability and productivity due to such symptoms as or the equivalent to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships; and the symptoms associated with the diagnosis of post-traumatic stress disorder under DSM-IV, but not listed under the General Rating Formula for Mental Disorders, do not more nearly approximate or equate to occupational and social impairment with reduced reliability and productivity under the General Rating Formula for Mental Disorders. 2. Bilateral hearing loss is manifested by auditory acuity level I in the right ear and auditory acuity level I in the left ear. 3. Chloracne was not affirmatively shown during service, chloracne was not manifest to a compensable degree within one year of separation from service, and chloracne, first shown documented after service, is otherwise unrelated to an injury, disease, or event, including exposure to Agent Orange, during service. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 30 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.7, 4.130, Diagnostic Code 9411 (2007). 2. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2007); 38 C.F.R. § 4.85, Diagnostic Code 6100 (2007). 3. Chloracne to include as due to exposure to Agent Orange was not incurred in or aggravated by service, and service connection for chloracne may not be presumed based on the one-year presumption for a disease associated with exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1116 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303(c), 3.307(a)(6), 3.309(e) (2007). Veterans Claims Assistance Act of 2000 (VCAA) The VCAA amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159. Duty to Notify Under 38 U.S.C.A. § 5103(a), VA must notify the claimant of the information and evidence not of record that is necessary to substantiate the claims, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. Under 38 C.F.R. § 3.159, VA must request that the claimant provide any evidence in the claimant's possession that pertains to the claims. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 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 v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Also, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the VA must provide at least general notice of that requirement to the claimant. Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Claim for Increase for Post-traumatic Stress Disorder The RO provided pre-adjudication, content-complying VCAA notice, including a PTSD questionnaire, by letter, dated in July 2003 on the underlying claim of service connection for post-traumatic stress disorder. Where, as here, service connection has been granted and an initial rating has been assigned, the claim of service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. And once a claim for service connection has been substantiated, the filing of a notice of disagreement with the RO's decision, rating the disability, does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, further VCAA notice under 38 U.S.C.A. § 5103(a) and § 3.159(b)(1) is no longer applicable in the claim for an initial higher rating for post-traumatic stress disorder. Dingess, 19 Vet. App. 473. The Claim for Increase for Hearing Loss The Claim of Service Connection for Chlorance The RO provided pre-adjudication VCAA notice by letters, dated in May 2004 and April 2005. The notice included the type of evidence needed to substantiate the claim for increase, namely, evidence indicating an increase in severity and the effect that worsening has on the claimant's employment and daily life. The veteran was notified of the evidence needed to substantiate the claim of service connection, namely, evidence of current disability; evidence of an injury or disease in service or an event in service, causing injury or disease; and evidence of a relationship between the current disability and the injury, disease, or event in service. The veteran was also notified that VA would obtain service records, VA records, and records of other Federal agencies and that he could submit private medical records or authorize VA to obtain private medical records on his behalf. The veteran was asked to submit any evidence that would include that in his possession. The notice included the provision for the effective date of the claim for increase. As for content of the VCAA notice, the documents substantially complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473 (2006) (notice of the elements of the claim, except for the degree of disability assignable of the claim for increase for hearing loss and the effective date and degree of disability assignable for the claim of service connection for chloracne); and of Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment and daily life, except general notice of the criteria of the Diagnostic Code under which the claimant is rated, which consists of a specific measurement or test result). To the extent that the VCAA notice did not include the degree of disability assignable for hearing loss and the Diagnostic Code for hearing loss under which the veteran is rated and general notice of the criteria, which consists of a specific measurement or test results, at this stage of the appeal, when the veteran already has notice of the pertinent Diagnostic Code and rating criteria as provided in the statement of the case, there is no reasonable possibility that further notice of the exact same information would aid in substantiating the claim. As the content error does not affect the essential fairness of the adjudication of the claim for increase for hearing loss, the presumption of prejudicial error as to the content error in the VCAA notice is rebutted. Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (compliance with the VCAA is not required if no reasonable possibility exists that any notice or assistance would aid the appellant in substantiating the claim); Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). To the extent that VCAA notice, pertaining to the degree of disability and the effective date for the claim of service connection for chloracne, was not provided, the notice was defective, but as the claim is denied no disability rating or effective date can be assigned as a matter of law and therefore there is no possibility of any prejudice to the veteran with respect to this limited VCAA content error. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims. The RO has obtained service medical records, VA records, and private records and had afforded the veteran VA examinations on the claims for increase. While the RO did not conduct a medical inquiry in the form of a VA examination for the veteran's chloracne, there is no evidence that the disability may be presumed to be related to herbicide exposure during service or may be associated with an established injury or disease in service. Under these circumstances, a medical examination with medical opinion is not required under 38 C.F.R. § 3.159(c)(4). As the veteran has not identified any additional evidence pertinent to the claims and as there are no additional records to obtain, the Board concludes that no further assistance to the veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The service medical records contain no complaint, finding, history or treatment for chloracne. Personnel records indicated the veteran left Vietnam on September 6, 1969. After service, private treatment records showed that in September 1971 the veteran was first treated for acne. The records revealed the veteran was treated for various skin problems from the 1970s to the 1990s. Treatment records from the Vet Center in Fort Worth, TX, showed that from August 2002 to May 2004 the veteran was treated for depressed mood, employment problems, marital problems, poor concentration, flashback, nightmares, social isolation, irritability, sleep disturbance, hypervigilance, suicidal thoughts and other symptoms of post traumatic stress disorder. On mental evaluation in April 2003 at the Vet Center, the veteran's speech was fluent and mood was pleasant. He indicated paranoia, appeared distrustful, reported short term memory loss and poor concentration. The veteran was alert and oriented. Insight and judgment were fair. The veteran reported having had 90 jobs since separation from service and noted he was never fired from a job and got along with his supervisors and co-workers. He described his household environment as chaotic and dysfunctional. His relationship with his children was fair and living situation was adequate. On VA examination in September 2002 for post-traumatic stress disorder, the veteran reported being depressed and denied suicidal thoughts. The examiner noted the veteran had trouble with abstract thinking, was oriented as to time, place and person. He was able to organize his thoughts, express himself, affect was normal and mood was mildly down. There was no psychosis, delusions, hallucinations or organicity. Memory and judgment were good, there was little insight. The diagnosis was no psychiatric disorder. Private medical records show that in October 2004 the veteran reported post-traumatic stress disorder symptoms to include bad dreams, poor concentration, self isolation and problems with his wife. On VA examination in December 2004 for post-traumatic stress disorder, the veteran reported feeling hostile towards his current wife. He has had several misdemeanors for domestic violence. The examiner noted the veteran reported practically all of the post traumatic stress disorder, which gave the impression that he learned this. He talked about survival guilt, nightmares, sleep disturbance and hypervigilance. The examiner noted the veteran had good contact with outside reality, was well oriented and his verbal skills were good. The diagnosis was mild post-traumatic stress disorder, somewhat chronic. The veteran's GAF score was between 55 and 60. The veteran's Form 9 Appeal received in August 2005, reported his wife observed panic attacks 3 to 4 times per month. In a statement received in October 2005, the veteran argued that chloracne may be manifested 20 years after exposure to a toxin. Private medical records dated in August 2005 indicated that a doctor who had retired provided the veteran with a diagnosis of chloracne. The veteran apparently indicated he was treated for chloracne after returning from Vietnam. In February 2008, the veteran's private doctor indicated the veteran developed a skin disorder from exposure to chemicals during service in Vietnam. During his Board hearing in February 2008, the veteran testified that he has problems getting along with people and does not need to interact with others at his current job at Bell Helicopters. He stated he has been employed there for the past 8 years. He indicated that he previously worked at various places because he could not get along with himself and others. Claims for Increase Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Bilateral Hearing Loss The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. The "puretone threshold average" as used in Tables VI, is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIa. 38 C.F.R. § 4.85(d). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86 the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater or when the puretone threshold at 1000 Hertz is 30 decibels or less, and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(a), (b). The record contains VA audiological evaluations, dated in July 2003 and May 2004. There also is a private audiogram dated in June 2004. In July 2003, the puretone thresholds in decibels at the tested frequencies of 1000, 2000, 3000, and 4000 Hertz in the RIGHT ear were 15, 25, 50, and 60, respectively; and in the LEFT ear 10, 20, 60, and 60, respectively. The puretone threshold average in the right ear was 38 and the average in the left ear was 38. Speech discrimination in the right ear was 96 percent and 96 percent in the left ear. In April 2003, the puretone thresholds in decibels at the tested frequencies of 1000, 2000, 3000, and 4000 Hertz in the RIGHT ear were 10, 30, 55, and 65, respectively; and in the LEFT ear 10, 25, 50 and 65, respectively. The puretone threshold average in the right ear was 40 and the average in the left ear was 38. Speech discrimination in the right ear was 96 percent and 92 percent in the left ear. Applying the results to TABLE VI, the findings of the VA examinations in July 2003 and May 2004 yield a numerical designation of I for the right ear as the average puretone decibel loss of 38 and 40 is in the range of between 0 to 41 average pure tone decibel loss, and the speech discrimination scores of 96 are in the range of between 92 and 100 percent speech discrimination. For the left ear, the average puretone decibel loss of 38 is in the range of between 0 to 41 average pure tone decibel loss, and the speech discrimination scores of 96 and 92 percent is in the range of between 92 and 100 percent speech discrimination, which yields a numerical designation of I. Applying the results to TABLE VI, entering the numeral designations of I for the right ear and I for the left ear to TABLE VII yields a disability rating of zero percent under Diagnostic Code 6100. Since the pure tone threshold at each of the four specified frequencies 1000, 2000, 3000, and 4000 Hertz is not 55 decibels or more, or the puretone threshold is not 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, an exceptional pattern of hearing impairment is not shown under 38 C.F.R. § 4.86. For these reasons, the preponderance of the evidence is against the claim for a compensable rating for bilateral hearing loss and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Post-Traumatic Stress Disorder Post-traumatic stress disorder is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. The criteria for the next higher rating, 50 percent are occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Global Assessment of Functioning is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score in the range of 41 to 50 represents serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score in the range of 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score in the range of 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Treatment records from the Vet Center showed that from May 2002 to May 2004 the veteran described symptoms of depression, poor concentration, flashback, social isolation, irritability, sleep disturbance, paranoia, short term memory loss, hypervigilance and suicidal thoughts. On VA examination in September 2002 he denied suicidal thoughts. On VA examination in December 2004, the veteran complained of nightmares, sleep disturbance and hypervigilance. The diagnosis was mild post-traumatic stress disorder with a GAF score between 55 and 60. A GAF score in the range of 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for a 50 percent have been met. It is the effect of the symptoms, rather that the presence of symptoms, pertaining to the criteria for a 50 percent rating, that is, occupational and social impairment with reduced reliability and productivity that determines the rating. As for the effect of the veteran's symptoms on work and family relations, the record shows that he has been employed by Bell Helicopters for the past 8 years. His job doesn't require interaction with other people. While the veteran appears to be socially withdrawn and has had numerous jobs since service, on mental evaluation in April 2003 he indicated he never had any specific problems with supervisors or co-workers. As for family relations, the veteran has been hostile towards his wife and reported having several misdemeanors for domestic violence, however he evaluated his relationship with his children as fair. As for the effect of the veteran's symptoms on reduced reliability and productivity, his mental evaluation in April 2003 at the Vet Center reported his complaints of short term memory problems, his insight and judgment were fair. On VA examination in September 2002, the veteran had problems with abstract thinking. On VA examinations in September 2002 and December 2004, the veteran was well oriented, verbal skills memory and judgment were good. The examiner in December 2004 provided a diagnosis of mild post-traumatic stress disorder with a GAF score between 55 and 60. Based on these findings, the symptoms have not resulted in occupational and social impairment with reduced reliability and productivity that are equivalent to the symptoms listed in the criteria for a 50 percent rating, namely, flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long- term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Also most of the symptoms listed in the criteria for a 50 percent rating are not demonstrated such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; disturbances of motivation and mood. For these reasons on the basis of the evidence of record, including GAF scores between 55 and 60, which were inconsistent with findings of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment and disturbances of motivation and mood, the Board finds that the effect of the symptomatology does not equate to or more nearly approximate the criteria for a 50 percent rating, that is occupational and social impairment with reduced reliability and productivity. Reconciling the various reports into a consistent disability picture, the veteran's symptoms have been not changed materially during the course of the appeal. Taking into account all the evidence and for the above reasons, the preponderance of the evidence is against a rating higher than 30 percent for post-traumatic stress disorder, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Claim for Service Connection for Chloracne Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era (beginning in January 1962 and ending in May 1975) shall be presumed to have been exposed during such service to herbicide agents, including an herbicide commonly referred to as Agent Orange. 38 U.S.C.A. § 1116(a)(3); 38 C.F.R. §§ 3.307, 3.309. Whenever VA's Secretary determines, on the basis of sound medical and scientific evidence, that a positive association exists between the exposure of humans to an herbicide agent and the occurrence of a disease in humans, the Secretary shall prescribe regulations providing that a presumption of service connection is warranted for that disease. 38 U.S.C.A. § 1116(b)(1). If a veteran was exposed to an herbicide agent during active military service, the following diseases will be presumed to have been incurred in service if manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). The presumptive period for these conditions is any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy have a presumptive period of one year after the last date on which the veteran was exposed to an herbicide agent during active service. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e); McCartt v. West, 12 Vet. App. 164 (1999). VA's Secretary has determined that a presumption of service connection based on exposure to herbicides to include Agent Orange used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 72 Fed. Reg. 32,395 (2007). Notwithstanding the aforementioned provisions relating to presumptive service connection, which arose out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2,725, 2,727-29 (1984), and the Agent Orange Act of 1991, Pub. L. No. 102-4, § 2, 105 Stat. 11 (1991), the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); 38 C.F.R. § 3.303(d). Analysis On the basis of the service medical records chloracne was not affirmatively shown to have been present during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). And as there is no competent evidence either contemporaneous with or after service that chloracne was noted during service, the principles of service connection pertaining to chroncity and continuity of symptomatology under 38 C.F.R. § 3.303(b) do not apply. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). After service, a diagnosis of chloracne was first documented in August 2005. As for service connection based on the initial documentation of the disability after service under 38 C.F.R. § 3.303(d), there is no medical evidence of a causal association or causal link between chloracne and an established injury or disease of service origin. To the extent that the veteran's private physician in February 2008, expressed an opinion that the veteran developed a skin disability from exposure to chemicals during the war, the physician did not identify which skin disability was due to the veteran's exposure to herbicides in Vietnam. Thus the private opinion does not appear to be expressed in definitive terms. The value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Additionally, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177 (180) (1995). See also Kightly v. Brown, 6 Vet. App. 200 (1994); Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record and conclusions of medical professionals which are not accompanied by a factual predicate in the record are not probative medical opinions). For these reasons, the Board rejects the medical opinion as evidence of a nexus between the veteran's chloracne and service. As for the veteran's statement and testimony, relating his chloracne to his military service, where as here, the question is one of medical causation, competent medical evidence is required to substantiate the claim because a lay person is not qualified through education, training, and expertise to offer an opinion on medical causation. 38 C.F.R. § 3.159; Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore the veteran's statements and testimony are not competent evidence on the question of medical causation, that is, the relationship between the current chloracne and his military service. The remaining question is whether chloracne is associated with the veteran's exposure to Agent Orange during his service in Vietnam. The veteran's personnel records indicate he left Vietnam on September 9, 1969. Afterwards, the record shows the veteran was first treated for skin problems in September 1971, when he was diagnosed with acne. Thus service connection for chloracne on a presumptive basis may not be granted as the first diagnosis of any acne disease was not within one year from the time when the veteran left Vietnam. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). For these reasons, the preponderance of the evidence is against the claim of service connection for chloracne and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER A compensable rating for bilateral hearing loss is denied. An initial rating higher than 30 percent for post-traumatic stress disorder is denied. Service connection for chloracne is denied. ____________________________________________ GEORGE E. GUIDO JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs