Citation Nr: 0813983 Decision Date: 04/29/08 Archive Date: 05/08/08 DOCKET NO. 01-02 298 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an increased evaluation for service- connected post-traumatic stress disorder (PTSD), currently 30 percent disabling. 2. Entitlement to service connection for diabetes mellitus, including as secondary to PTSD and secondary to herbicide exposure. 3. Entitlement to service connection for coronary artery disease, including as secondary to PTSD and secondary to herbicide exposure. 4. Entitlement to service connection for hypertension, including as secondary to PTSD and secondary to herbicide exposure. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Amy R. Grasman, Associate Counsel INTRODUCTION The veteran served on active duty from May 1966 to May 1968. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2000 RO decision denying an increased evaluation for PTSD and from a January 2005 RO decision denying service connection for diabetes, coronary artery disease and hypertension. In February 2008, the veteran testified in a video conference hearing in front of the undersigned Veterans Law Judge. The transcript of the hearing is associated with the claims file and has been reviewed. FINDINGS OF FACT 1. The veteran has been notified of the evidence necessary to substantiate his claim, and all relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. PTSD is manifested by sleep difficulties, frequent nightmares, night sweats, irritability, nervousness, paranoia, forgetfulness, depression, avoidance of others, agitation, difficulty concentrating, uncontrolled temper, impaired social interaction, fair concentration and attention, short term memory deficit, thoughts of hurting others, depressed mood, restricted affect, recurrent and intrusive distressing recollections, obsessive behaviors, feelings of detachment, estrangement from others, an inability to form meaningful relationships, outbursts of anger and hypervigilance; but no abnormal motor behavior, psychosis, hallucinations, suicidal ideations, illogical speech, near-continuous panic attacks, spatial disorientation, neglect of personal appearance or hygiene, gross impairment in thought processes or communication, persistent delusions, or grossly inappropriate behavior. 3. The veteran served in Korea from November 1966 to December 1967. 4. The competent medical evidence does not show that diabetes mellitus manifested in service, within one year after service, is related to service, was caused by herbicide exposure in service or was caused by or related to a service- connected disability. 5. The competent medical evidence does not show that coronary artery disease manifested in service, within one year after service, is related to service, was caused by herbicide exposure in service or was caused by or related to a service- connected disability. 6. The competent medical evidence does not show that hypertension manifested in service, within one year after service, is related to service, was caused by herbicide exposure in service or was caused by or related to a service- connected disability. CONCLUSIONS OF LAW 1. The criteria for a 50 percent evaluation for service- connected PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.7, 4.130, Diagnostic Code 9411 (2007). 2. Diabetes mellitus was not incurred in active service, may not be presumed to have been incurred therein and was not proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 3. Coronary artery disease was not incurred in active service, may not be presumed to have been incurred therein and was not proximately due to or the result of a service- connected disease or injury. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 4. Hypertension was not incurred in active service, may not be presumed to have been incurred therein and was not proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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 ask the claimant to provide any evidence in his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the present case, the unfavorable AOJ decision that is the basis of this appeal for an increased evaluation for PTSD was already decided and appealed prior to the enactment of the current section 5103(a) requirements in 2000. The Court acknowledged in Pelegrini that where, as here, the § 5103(a) notice was not mandated at the time of the initial AOJ decision, the AOJ did not err in not providing such notice. Rather, the appellant has the right to a content complying notice and proper subsequent VA process. Pelegrini, 18 Vet. App. at 120. The duty to notify regarding the PTSD claim was not satisfied prior to the initial unfavorable decision on the claim by the AOJ. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial AOJ decision by way of a letter sent to the appellant in June 2003 that fully addressed all four notice elements. The letter informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence. The appellant was also asked to submit evidence and/or information in his possession to the AOJ. Although the notice letter was not sent before the initial AOJ decision in this matter, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case by way of supplemental statements of the case in August 2004, February 2006 and June 2007 after the notice was provided. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. With regard to the increased evaluation claim included in this decision, the Board is aware of the Court's recent decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In Vazquez-Flores, the Court found that, at a minimum, adequate VCAA notice requires that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay 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; (2) 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 Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. In this case, the Board is aware that the June 2003 VCAA letter does not contain the level of specificity set forth in Vazquez-Flores. However, the Board does not find that any such procedural defect constitutes prejudicial error in this case because of evidence of actual knowledge on the part of the veteran and other documentation in the claims file reflecting such notification that a reasonable person could be expected to understand what was needed to substantiate the claim. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). In this regard, the Board is aware of the veteran's statements in his February 2008 hearing, his numerous written statements and his statements in the VA examinations. In these statements, the veteran described the effect of the service-connected disability on employability and daily life. Particularly, the veteran described how his PTSD symptoms affect his work by creating stress during shift changes and his lack of patience with co-workers and children. He also stated that PTSD caused him to verbally and physically abuse his wife. These statements indicate an awareness on the part of the veteran that information about such aspects of his life were necessary to substantiate a claim for a higher evaluation. Significantly, the Court in Vazquez-Flores held that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his claim." Id, citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). This showing of actual knowledge satisfies the first and fourth requirements of Vazquez-Flores. Additionally, and particularly in light of the veteran's lay assertions of effects of the service-connected disability on employability and daily life, the Board does not view the disorder at issue to be covered by the second requirement of Vazquez-Flores, and no further analysis in that regard is necessary. Finally, the veteran has also demonstrated actual knowledge of the rating criteria utilized in the present case. The statement of the case and numerous supplemental statements of the case set forth the criteria. The veteran was accordingly made well aware of the requirements for an increased evaluation pursuant to the applicable diagnostic criteria, and such action thus satisfies the third notification requirement of Vazquez-Flores. Regarding the service connection claims, the VCAA duty to notify was satisfied by way of a letter sent to the appellant in September 2004 that fully addressed all four notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence. The appellant was also asked to submit evidence and/or information in his possession to the AOJ. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the veteran was provided this notice in a March 2006 letter. Any error regarding this notice was harmless given that service connection is being denied, and hence no rating or effective date will be assigned with respect to this claimed condition. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). In this case, the appellant was afforded VA medical examinations for PTSD in March 2000, August 2003, June 2004 and April 2006. Regarding the service connection claims for diabetes mellitus, coronary artery disease and hypertension, the service medical records do not indicate that these disabilities manifested in service. There was no treatment in the service medical records for these disabilities and a chronic disability was not noted at the separation examination. Additionally, the post-service medical records do not suggest the etiologies of these disabilities. In view of the objective evidence of record, the Board finds the veteran's current assertions alone in the face of this objective evidence not credible, and thus do not require VA to provide an examination. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (in determining whether lay evidence is satisfactory the Board may properly consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the veteran). The Court has held, in circumstances similar to this, where the supporting evidence of record consists only of a lay statement, that VA is not obligated, pursuant to 5103A(d), to provide a veteran with a medical nexus opinion. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (a medical opinion was not warranted when there was no reasonable possibility that such an opinion could substantiate the veteran's claim because there was no evidence, other than his own lay assertion, that reflected an injury or disease in service that may be associated with his symptoms). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service medical records, Social Security Administration Records, DD Form 214, private medical records and VA medical records. The veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). INCREASED EVALUATION Ratings for service-connected disabilities are determined by comparing the symptoms the veteran is presently experiencing with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Also, when making determinations as to the appropriate rating to be assigned, VA must take into account the veteran's entire medical history and circumstances. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The veteran's service-connected PTSD was assigned a 30 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating requires evidence of 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives; own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness'" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (1994) at 32). A score of 51-60 represents "[m]oderate 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)." Id. A score of 61-70 illustrates "[s]ome 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, has some meaningful interpersonal relationships." Id. The Board finds that the veteran is entitled to a 50 percent evaluation for service-connected PTSD. The evidence of record consists of numerous treatment and therapy records, VA Compensation and Pension Examinations, statements from a social worker at the Vet Center and statements from the veteran and his wife. The Board has reviewed all the medical evidence of record and the February 2008 hearing transcript. The most recent VA Compensation and Pension Examination in April 2006 shows that the veteran had seep difficulties and frequent nightmares. The veteran reported nightmares on a nightly basis and he would sleep 3-4 hours per night. He had night sweats, irritability, nervousness, paranoia in crowds, forgetfulness and depression. The veteran reported that he thought people were conspiring against him. He reported that he had not lost work due to his PTSD. He worked third shift to avoid interaction with others, however he became agitated and irritable at work. He had difficulty concentrating and controlling his temper. Although he was married for 12 years, he had few friends and little social interaction. The veteran was on time for his evaluation, was clean and well groomed. There was no abnormal motor behavior. He had normal posture, gait and facial expressions. His voice was soft, his speech was slow and he articulated clearly. He was oriented and his answers to questions were logical and relevant. There was no evidence of psychosis and no hallucinations. His attention and concentration were fair. He had short term memory deficit. There were no suicidal ideations or attempts. He has past thoughts of hurting others with no specific plan. He had a depressed mood, restricted affect and reported signs of paranoia and depression. The examiner found that the veteran had recurrent and intrusive distressing recollections of stressors, nightly dreams, and physiological reactivity including night sweats and restless sleep. He had obsessive behaviors which included watching news about the Iraq war which precipitated symptoms of PTSD. He had feelings of detachment and estrangement from others. He had an inability to form meaningful relationships with others and avoided people. The examiner concluded that the veteran had difficulty falling and staying asleep, irritability, outbursts of anger and difficulty concentrating. He was hypervigilant and avoided his wife. PTSD caused significant distress and impairment in social and occupational functioning. The examiner assigned a GAF of 60. The Board also reviewed the June 2004, August 2003, March 2000 and October 1998 VA examinations and finds that the veteran's symptoms of PTSD were constant and consistent with the April 2006 examination. Additionally the GAF scores ranged from 55 to 65 in the VA records. Therapy notes were also reviewed and showed symptoms consistent with the findings of the April 2006 VA examiner. In March 2007, the veteran reported persistent nightmares. His GAF was 51-60. VA treatment notes in February 2007 showed chronic persistent symptoms which were stable on medications and long-term therapy. The veteran reported difficulties with increased responsibilities at work and trusting others. In January 2007, the veteran reported losing things, flashbacks, nightmares, intrusive and distracting thoughts, irritability and anger. In July 2006, the veteran was reactive, irritable, would verbally assault his wife, had nightmares, hypervigilance, feelings of detachment, depersonalization, derealization, numbness, sleep disturbance, excessive worry, racing thoughts, depressive thoughts and occasional grandiose and expansive thoughts. In August 2004, the veteran reported increased panic attacks and anxiety. The veteran's social worker also submitted statements on behalf of the veteran. The veteran attended individual and group therapy regularly. The veteran reported symptoms consistent with the VA records. The veteran's wife also submitted a statement in July 2003 and indicated that the veteran had periods of depression, appetite and sleep disturbance. He had feelings of helplessness and hopelessness and lowered self esteem. He was anxious, easily frustrated, moody, had poor concentration and increased periods of memory loss. The veteran's relationship with his wife was strained due to symptoms of PTSD and they attended counseling sessions. Based on all the medical evidence of record, the Board finds that the veteran's symptoms warrant a 50 percent evaluation for PTSD. He had occupational and social impairment as evidenced by his difficulties at work and with authority and his impaired social relationships due to isolation behavior, estrangement and detachment. He had restricted affect, memory loss, poor concentration and forgetfulness. His judgment was fair and his mood was depressed. His relationships with his family and co-workers were strained as evidenced by letters from his employer and his wife's statements. Additionally, the Board has considered the frequent nightmares, nervousness, paranoia, thoughts of hurting others, and hypervigilance. Furthermore, the GAF scores indicate moderate symptoms of PTSD which is consistent with a 50 percent rating. The Board finds that a 70 or 100 percent rating is not warranted because he did not have suicidal ideation, illogical speech, near-continuous panic attacks, spatial disorientation, neglect of personal appearance or hygiene, gross impairment in thought processes or communication, persistent delusions, persistent hallucinations or grossly inappropriate behavior. The Board further notes that to the extent that the veteran's service-connected disability affects his employment, such has been contemplated in the assignment of the current 50 percent schedular evaluation. The evidence does show that the veteran had difficulty with a structured schedule and stress at work. However, the record does not reflect that the disability at issue caused marked interference with employment or necessitated any frequent periods of hospitalization, such that application of the regular schedular standards is rendered impracticable. In fact, the veteran indicated that he had not missed work because of his PTSD symptoms. Hence, referral to the RO for consideration of the assignment of an extra-schedular evaluation under 38 C.F.R. § 3.321 (2007) is not warranted. SERVICE CONNECTION The veteran claims service connection for diabetes mellitus, coronary artery disease and hypertension. The veteran claims that these disabilities were caused by herbicide exposure in service and as secondary to his PTSD. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). This may be shown by affirmative evidence showing inception or aggravation during service or through statutory presumptions. Id. To establish direct service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). 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. See 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and chronic diseases such as diabetes mellitus, coronary artery disease and hypertension manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. In this case, the veteran was diagnosed with diabetes mellitus in 1987, coronary artery disease in August 1997, and hypertension in August 1997. The Board notes that the medical evidence of record does not show manifestation of these disabilities within one year after separation from service, therefore, service connection is not presumed. Regarding the veteran's assertion that diabetes mellitus, coronary artery disease and hypertension were caused by exposure to Agent Orange in the demilitarized zone (DMZ) in Korea, VA has established a procedure for verifying exposure to herbicides along the DMZ in Korea. See M21-1IMR, Part IV, Subpart ii, Chapter 2, Section C. The Department of Defense has acknowledged that herbicides were used in Korea from April 1968 through July 1969 along an area of the DMZ. The Department of Defense publication with respect to herbicide agent use in Korea during the stated period includes a list of specific military units. The veteran's service personnel records indicate that his period of service in Korea was with the Combat Brigade of the 2nd Infantry Division, 1st Battalion, 23rd Infantry which is among the listed units in the Department of Defense Publication. See M21-1IMR, Part IV, Subpart ii, Chapter 2, Section C. As noted, DOD has confirmed that Agent Orange was used along the Korean DMZ from April 1968 through July 1969. According to the veteran and his military records, however, the veteran was in Korea from November 1966 to December 1967. As the veteran did not serve in Korea between April 1968 and July 1969, the veteran is not entitled to the presumptions found in 38 C.F.R. § 3.309(e). Furthermore, the veteran has not established that he was personally exposed to the herbicide agents, and there is insufficient evidence to imply that the veteran was exposed to Agent Orange herbicide from November 1966 to December 1967. The Board is cognizant of the veteran's assertion that he was exposed, but there is no corroboration or objective verification of his allegations. Inasmuch as the record does not establish exposure to herbicides or that he was in an area at the time herbicides were used, entitlement to service connection for his disabilities on a presumptive basis cannot be granted. Regarding direct service connection, the service medical records are silent for treatment for manifestations of diabetes, heart disease or hypertension. In February 1966, the veteran reported that he did not have high or low blood pressure. The veteran was clinically evaluated as normal in all areas of examination. There were no complaints of symptoms of his claimed disabilities in the service treatment records. The separation examination in March 1968 also clinically evaluated the veteran as normal. After reviewing the service medical records, there were no manifestations of the claimed disabilities in service. Additionally, the competent medical evidence of record does not show that the veteran's claimed disabilities are related to service or to a service-connected disability. No doctor has ever opined that his disabilities were related to any remote incident in service. Without competent medical evidence linking the veteran's disability to service, service connection is not warranted. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2007). However, VA will not concede that a non-service- connected disease was aggravated by a service-connected disease unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease. See 38 C.F.R. § 3.310(b) (2007). The January 2006 VA Compensation and Pension Examination shows that PTSD did not cause or permanently aggravate diabetes mellitus, coronary artery disease or hypertension. The examiner noted that PTSD can cause a temporary aggravation, however there is no evidence of permanent aggravation. In the medical evidence of record, there was no evidence of accelerated or aggravated diabetes mellitus, coronary artery disease or hypertension. The examiner found that diabetes mellitus was uncontrolled because of the veteran's diet. The examiner opined that diabetes mellitus, coronary artery disease and hypertension were less likely than not caused by or permanently aggravated beyond the normal progression by the veteran's service-connected PTSD. Based on the foregoing medical opinion, the Board finds that the veteran is not entitled to service connection for diabetes mellitus, coronary artery disease or hypertension on a secondary basis. The VA opinion does not show that the claimed disabilities are caused by PTSD or any service- connected disability. The Board has also considered the contentions of the veteran that his claimed disabilities were caused by service and were aggravated by his PTSD. However, as a layman, without the appropriate medical training and expertise, he is not competent to provide a probative opinion on a medical matter such as etiology or aggravation. While a layman such as the veteran can certainly attest to his in-service experiences and current symptoms, he is not competent to provide an opinion relating that disability to service or to a service- connected disability. (The opinion of his spouse, a psychologist, is outweighed by the VA medical opinion.) See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply and the veteran's claim for service connection for diabetes mellitus, coronary artery disease and hypertension must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). (CONTINUED ON NEXT PAGE) ORDER A 50 percent evaluation for PTSD is granted, subject to controlling regulations affecting the payment of monetary awards. Service connection for diabetes mellitus, including as due to herbicide exposure and secondary to PTSD, is denied. Service connection for coronary artery disease, including as due to herbicide exposure and secondary to PTSD, is denied. Service connection for hypertension, including as due to herbicide exposure and secondary to PTSD, is denied. ____________________________________________ John E. Ormond, Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs