Citation Nr: 0815197 Decision Date: 05/08/08 Archive Date: 05/14/08 DOCKET NO. 05-34 711 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for post-traumatic stress disorder (PTSD), and if so, is service connection warranted. 2. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for bilateral hearing loss disability and if so, is service connection warranted. 3. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for tinnitus disability and if so, is service connection warranted. 4. Entitlement to service connection for congenital heart murmur, to include cardiac disability. 5. Entitlement to service connection for hypertension, claimed as secondary to PTSD. 6. Entitlement to service connection for anxiety, claimed as secondary to PTSD. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The veteran served on active duty from August 1970 to December 1973. This matter comes to the Board of Veterans' Appeals (Board) from a November 2004 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A notice of disagreement was filed in December 2004, a statement of the case was issued in February 2005, and a substantive appeal was received in October 2005. The veteran testified at a RO hearing in May 2005. In his October 2005 substantive appeal, the veteran requested a central office Board hearing; however, upon further inquiry in December 2006 the veteran indicated that he did not desire a Board hearing. FINDINGS OF FACT 1. In a July 1997 RO decision, entitlement to service connection for PTSD, bilateral hearing loss disability, and tinnitus disability was denied; the veteran did not file a notice of disagreement. 2. In September 2003, the veteran filed a claim to reopen entitlement to service connection for PTSD, bilateral hearing loss disability, and tinnitus disability. 3. Additional evidence received since the RO's July 1997 decision is new to the record, relates to an unestablished fact necessary to substantiate the merits of the claims of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability, and raises a reasonable possibility of substantiating the claims. 4. The veteran did not engage in combat with the enemy, and his claimed stressors have not been corroborated. 5. Any current PTSD is not related to the veteran's active duty service. 6. Bilateral hearing loss disability was not manifested during the veteran's military service or for many years thereafter, nor is bilateral hearing loss disability otherwise related to the veteran's service. 7. Tinnitus disability was not manifested during the veteran's military service or for many years thereafter, nor is tinnitus disability otherwise related to the veteran's service. 8. Congenital heart murmur and a cardiac disability were not manifested during active service, or within one year of discharge from service, nor are such disabilities otherwise related to the veteran's service. 9. Hypertension was not manifested during service, or within one year of discharge from service, nor is such disability otherwise related to the veteran's service or any service- connected disability. 10. Anxiety was not manifested during service nor is such disability otherwise related to the veteran's service or any service-connected disability. CONCLUSIONS OF LAW 1. The July 1997 RO decision is final. 38 U.S.C.A. § 7105 (West 2002). 2. New and material evidence has been received since the July 1997 denial, and the claims of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability, are reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2007). 3. PTSD was not incurred in or aggravated during the veteran's active duty service. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2007). 4. Bilateral hearing loss disability was not incurred in or aggravated by the veteran's active military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 5. Tinnitus disability was not incurred in or aggravated by the veteran's active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 6. Congenital heart murmur and cardiac disability were not incurred or aggravated by the veteran's active duty service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 7. Hypertension was not incurred in or aggravated by the veteran's active duty service, nor is hypertension proximately due to or caused by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 8. Anxiety was not incurred in or aggravated by the veteran's active duty service, nor is anxiety proximately due to or caused by a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) On November 9, 2000, the President signed into law the VCAA, which has been codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Under the VCAA, VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for Veteran Claims' (Court's) decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this case, VA satisfied its duties to the veteran in VCAA letters issued in October 2003, November 2003, and January 2004. The letters predated the November 2004 rating decision. See id. Thereafter, in August 2006 and November 2007, VA issued a VCAA letter pertaining to the merits of his claimed PTSD. Collectively, the VCAA letters notified the veteran of what information and evidence is needed to substantiate his claims, as well as what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and the need for the claimant to submit any evidence in his possession that pertains to the claims. Id.; but see VA O.G.C. Prec. Op. No. 1-2004 (Feb. 24, 2004). The VCAA letters have clearly advised the veteran of the evidence necessary to substantiate his claims. In March 2006, the veteran was provided with notice of the types of evidence necessary to establish a disability rating and the type of evidence necessary to establish an effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Despite initial inadequate notice provided to the veteran, the Board finds no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the appellant has been prejudiced thereby). In any event, since the Board concludes below that the preponderance of the evidence is against entitlement to service connection, any questions as to the appropriate disability rating and effective date to be assigned are rendered moot. The Board also finds that VA has complied with all assistance provisions of VCAA. The evidence of record contains the veteran's service medical records, service personnel records, post-service VA medical records from the VA Medical Center (VAMC) in Dallas, Texas, and post-service private evaluations pertaining to his claimed PTSD. The veteran has reported that he sought treatment at the Dallas VAMC for hypertension from 1986 to 1989. The RO requested such records; however, the Dallas VAMC reported that the veteran did not have any medical records for such period. The Board finds that no prejudice results as there is no dispute that the veteran has a post-service diagnosis of hypertension. There is otherwise no indication of relevant, outstanding records which would support the veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). The evidence of record contains a VA examination pertaining to the issues of entitlement to service connection for bilateral hearing loss disability and tinnitus disability. As will be discussed in more detail below, the Board has determined that further examinations and opinions are not necessary with regard to the other claims of service connection. For all the foregoing reasons, the Board concludes that VA's duties to the veteran have been fulfilled with respect to the issues on appeal. II. New & Material Generally, an unappealed RO denial is final under 38 U.S.C.A. § 7105(c), and the claim may only be reopened through the receipt of "new and material" evidence. If new and material evidence is presented or secured with respect to a claim that has been disallowed, VA must reopen the claim and review its former disposition. 38 U.S.C.A. § 5108. See Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). The veteran's request to reopen his claims of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability was received in September 2003, and the regulation applicable to his appeal provides that new and material evidence means existing evidence that by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a) (2007). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In April 1994, the veteran filed claims of service connection for, in pertinent part, PTSD, bilateral hearing loss disability, and tinnitus disability. In October 1994, the veteran underwent a VA examination for evaluation related to his claimed PTSD. Upon mental status examination, the examiner diagnosed mild chronic alcohol abuse and chronic incapacity to work mild, and incapacity to socialize mild. No diagnosis of PTSD was rendered. He underwent an October 1994 VA audiological examination which reflected moderate- severe sensorineural hearing loss in the left ear, and normal hearing in the right ear, and subjective complaints of tinnitus. In a November 1994 rating decision, service connection for PTSD was denied on the basis of no diagnosis; service connection for bilateral hearing loss disability was denied on the basis that although VA audiometric findings reflected hearing loss, his separation examination did not reflect hearing loss; and, service connection for tinnitus disability was denied on the basis that there was no evidence that tinnitus was due to injury or acoustic trauma during service. The veteran did not file a notice of disagreement; thus, the RO's decision is final. 38 U.S.C.A. § 7105(c). In October 1995, the veteran filed a claim to reopen entitlement to service connection for hearing loss disability. He did not submit any new evidence in support of his claim. A June 1996 rating decision denied service connection on the basis that new and material evidence had not been received. The veteran did not file a notice of disagreement; thus, the RO's decision is final. 38 U.S.C.A. § 7105(c). In September 1996, the veteran filed a claim to reopen entitlement to service connection for PTSD, bilateral hearing loss disability, and tinnitus disability. In support of his claim for PTSD, he submitted VA outpatient treatment records dated in 1994 reflecting an impression of PTSD with depression exacerbated by external stressors. Such VA outpatient treatment records did not reflect any treatment related to bilateral hearing loss or tinnitus disabilities. In a July 1997 rating decision, the RO determined that new and material evidence had not been received to reopen the claims, and such claims were denied. The veteran did not file a notice of disagreement; thus, the RO's decision is final. 38 U.S.C.A. § 7105(c). In September 2003, the veteran filed an informal claim of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability. Evidence received since the RO's July 1997 decision is both new and material. Pertaining to his claimed PTSD, the veteran has submitted a September 2003 private evaluation from M. H. B., M.D., reflecting a diagnosis of PTSD; a February 2007 private evaluation from M. B. F., M.D., reflecting a diagnosis of PTSD; and, the veteran has also submitted statements and testimony pertaining to his claimed stressors. Since the veteran's initial claim was denied on the merits on the basis of no diagnosis, and as the veteran had not provided any details pertaining to his claimed stressors, the Board has determined that such evidence is new and relates to an unestablished fact necessary to substantive the merits of the claim. With regard to his claimed bilateral hearing loss and tinnitus disabilities, the veteran underwent a VA audiological examination in June 2005 which reflects diminished hearing loss, and the veteran has also submitted a December 2006 private audiological opinion from J. A. W., M.D., pertaining to such claims. Since the veteran's initial claims were denied on the basis that any hearing loss and tinnitus were not related to service, the Board has determined that such evidence is new and relates to an unestablished fact necessary to substantive the merits of the claims. The claims of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability, are reopened. 38 U.S.C.A. § 5108. As detailed, the Board has determined that new and material evidence has been presented to reopen the claims of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability. It is acknowledged that the RO has not yet reviewed the veteran's appeal on a de novo basis with regard to the claims of service connection for PTSD, and bilateral hearing loss and tinnitus disabilities. It is also acknowledged that in Bernard v. Brown, 4 Vet. App. 384, 394 (1993), the Court held that when the Board addresses in its decision a question that has not been addressed by the RO, it must consider (1) whether the claimant has been given both adequate notice of the need to submit evidence or argument on that question and an opportunity to submit such evidence and argument and to address that question at a hearing, and (2) whether, if such notice has not been provided, the claimant has been prejudiced thereby. See also Sutton v. Brown, 9 Vet. App. 553, 564 (1997); Curry v. Brown, 7 Vet. App. 59, 66-67 (1994). Generally, Bernard stands for the proposition that the Board should not consider issues not considered by the RO decision on appeal to it and if the Board does so it should do so only with the full and informed participation of the appellant. Id. In this regard, it is noted that while the RO initially determined in the November 2004 rating decision that new and material evidence had not been received to reopen the claims of service connection for PTSD, bilateral hearing loss disability, and tinnitus disability, in the subsequent February 2005 statement of the case, and supplemental statements of the case dated in August 2005, March 2006, November 2006, April 2007, and January 2008, the RO conducted a merits analysis pertaining to the respective claims. Thus, the RO considered the evidence discussed hereinabove in adjudicating the veteran's claims. The veteran has been given an opportunity to submit medical evidence, personal statements, lay statements, and testimony pertaining to the merits of the claims. The VCAA letters included information concerning direct service connection as to all of the claimed issues. In addition, the statement of the case and subsequent supplemental statements of the case contained the pertinent laws and regulations regarding service connection claims on a direct basis. Accordingly, any remand by the Board for initial RO adjudication would constitute needless delay since due process has already been served. The Board finds that additional development is not warranted and adjudication in the first instance will not prejudice the veteran's claims on appeal or his enjoyment of any statutory and regulatory procedural rights. Bernard, supra. III. Service Connection Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, cardiovascular-renal disease, and organic diseases of the nervous system, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any 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). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service- connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Court has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). After considering all information and lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). PTSD Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f). The provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a mental disorder conform to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). The veteran's DD Form 214 reflects that he had 8 months and 10 days of foreign and/or sea service. He served as a motor transport operator, and such related civilian occupation was a chauffeur. He was awarded the National Defense Service Medal, Vietnam Service Medal, and Specialist Qualified Badge (Rifle M-16). Service personnel records reflect that he served in Vietnam from May 31, 1972, to February 18, 1973. VA treatment records reflect that in February 1988 the veteran was hospitalized for six days because he was afraid he might hurt somebody. He reported a history of amphetamine abuse in the past. He reported nightmares and flashbacks since returning from Vietnam that had become worse in the last two and a half years. On mental status examination, he had a dysphoric mood and flat affect. There was no evidence of thought disorders, homicidal ideation, or suicidal ideation. He was cognitively intact. He was referred to the PTSD group for evaluation and possible treatment. However, through the course of a long holiday weekend, he became frustrated at his lack of treatment, including not yet being seeing by the PTSD group, and wished to leave the hospital and return for outpatient treatment. The discharge diagnosis was PTSD, chronic, rule out, and alcohol abuse, continuous. In April 1994, the veteran was referred by a National Service Organization for an evaluation at the VAMC. He endorsed symptoms of nightmares, intrusive memories, sensitivity to loud sounds, feeling closed in and paranoid in crowds, functions best in isolation, has insomnia and irritable mood. He reported that symptoms were severe immediately after return from Vietnam. He tried to wait it out without treatment. He noted improvement after 1986 while he was employed as a long haul trucker and spent most of his time alone. Symptoms worsened two years later when he got a divorce, had an accident and got a DWI. He admitted that he was sober from 1988 to 1992 but began drinking again in 1992. He stopped drinking 4 months prior to the VA evaluation. He denied any street drugs but reported that a buddy died on drugs in Vietnam. The examiner's assessment was PTSD, and history of alcohol abuse in remission. The veteran continued seeking VA outpatient treatment through July 1994. In July 1994, the veteran reportedly described several traumatic incidents occurring during service. He reported being trapped in a bunker for three days after a rocket/mortar attack on his position. This occurred reportedly in the final days of American participation in Vietnam in 1973, and he and two other survivors were not extracted from the bunker for three days in which they were in total darkness. He also reported combat dreams. In October 1994, the veteran underwent a VA psychiatric evaluation. He reported that he went to Vietnam in April 1972, and was stationed in Cam Rahn Bay as a truck driver and he had an M-16 and a 45. He reported that he was not wounded nor was he a prisoner-of-war. His group was split up, and went to Nha Trang and Plei Ku and he drove between there and Da Nang. He reported drinking a lot of alcohol while in Vietnam. He denied drug use. He denied killing anyone, including women or kids. He reported being in Vietnam for 10 months, leaving in February 1973. He reported that he was asking for an early out and got a DWI in Dallas and spent 97 days in jail and had a summary court martial by his choice for being AWOL and served out the additional time and got a regular discharge. He reported employment as a truck driver since service, until he got a second DWI in March 1994. He reported being bothered by crowds and authority. He reported trouble sleeping, and has nightmares and remembrances of things in Vietnam of bodies and so forth. He dreams of a three year old girl that a sergeant shot in the back of her head because she was carrying a grenade. He claimed he almost got brought up on charges for not doing it himself. He reported that he came to the hospital in 1986 and did not know where he was or who he saw. They wanted to send him to the alcohol ward but he left after four days. Upon mental status examination, the examiner diagnosed mild chronic alcohol abuse and chronic incapacity to work mild, and incapacity to socialize mild. In September 2003, the veteran underwent a private evaluation with Dr. M. H. B. The veteran reported that his nightmares of Vietnam had become more frequent since he had a heart attack. He recalled a man stepping on a land mine and being said to be dead. He was told he was dead, and he zipped the body bag up and recalled looking into his eyes. He reported later running into the man in Fort Worth; he reportedly had not died. He reported that there a lot of "other incidents, and I put a lot of men in body bags." He reported not wanting to be around others who were not in combat in Vietnam. Upon mental status examination, Dr. M. H. B. diagnosed PTSD chronic, and rule out major depression. In a statement from the veteran received in October 2003, he reported that during service in Vietnam he was a truck driver. He was driving in a truck convoy and they stopped in a village to take a break. Approximately six GIs were standing beside a jeep and he turned around to look and there was a 3 or 4 year old girl that came out with a grenade and the pin was pulled out. He hollered for her to stop to keep her from killing the six men. He pulled out his 45 and shot her before the grenade detonated. He claimed another incident in which a man stepped on a land mine and blew off his right leg. He claimed that the medics could not find any vital signs and he was zipped into a body bag. He claimed that he saw the man in 1984 at a store in Fort Worth, as the man had not actually died. In May 2005, the veteran testified at a RO hearing. He reported that he escorted convoys, and received the Bronze star. He reported that he saw approximately 20 guys get killed and also saw guys being shot at. He did not know any of the soldiers killed because they were the convoy supply drivers; never the units that he was escorting. He reported initially seeking treatment at the Dallas VAMC in 1986, and the last time he went to group therapy was in 1989. He reported nightmares due to the girl with the grenade that he had to shoot. In another statement received from the veteran in January 2007, the veteran again claimed the PTSD stressor related to the girl with the grenade, and indicated that such incident occurred in September 1972. A February 2007 psychiatric evaluation from Dr. M. B. F. reflects the veteran's report that he had been claiming disabilities for 20 years but he was denied because he signed a waiver when he initially went into the military because he had an orthopedic issue that he could never hold the military accountable for future claims. He reported that none of his medical or military records could be produced, even though he is a Vietnam veteran who saw much action in combat, has PTSD symptoms, and has received mental health counseling, including a psychiatric hospitalization. He reported significant problems with alcohol since returning from Vietnam, but denied drug use. He reported that he was directly injured in Vietnam and received the Purple Heart and Silver Star but "sort of lost it in his duffle bag when he got back stateside." Dr. M. B. F. diagnosed PTSD, and stated that he met all of the DSM-IV criterion for chronic PTSD. Dr. M. B. F. recommended a full reevaluation based on his combat record and to try and obtain the military records, especially since he was a recipient of the Purple Heart in Vietnam, when he was injured by incoming mortar shells. Dr. M. B. F. noted that the mortar shells blew out his eardrums, and he suffered hearing loss and orthopedic injury as a result. The veteran claims service connection for PTSD which he asserts was incurred due to military service. Applying the facts in this case to the criteria set forth above, the Board finds that the weight of the probative evidence of record is against a finding that any PTSD is etiologically related to active service. As a result, service connection for this disability must be denied. Initially, despite the veteran's contentions otherwise, the Board finds that there is no evidence that the veteran participated in combat during active service. With regard to the question of whether the veteran engaged in combat, the phrase "engaged in combat with the enemy," as used in 38 U.S.C. § 1154(b), requires that a veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. Mere service in a combat area or combat zone does not in itself lead to the conclusion that an individual engaged in combat. VAOPGCPREC 12-99 (October 18, 1999). The veteran's military personnel records reflect that he served as a driver. As detailed hereinabove, the veteran has reported receipt of the Purple Heart, Silver Star, and Bronze Star due to his combat service in Vietnam. His records, however, do not indicate that he participated in combat, nor that he was in receipt of any such decorations or awards or any other decorations or awards suggestive of combat status. Because the record does not demonstrate that the veteran engaged in combat with the enemy, his alleged in-service stressors must be corroborated. The Board has carefully reviewed all of the evidence to include the service medical records, post-service VA treatment records, VA examination, post-service private evaluations, and the veteran's stressor statements and testimony. The Board acknowledges an assessment of PTSD in VA outpatient treatment records dated in 1994, and both private evaluations reflect diagnoses of PTSD. It appears that such diagnoses have been rendered based on the veteran's purported in-service experiences and post-service symptomatology. The primary question which must be resolved in this decision is whether the veteran sustained a qualifying stressor within the requirements of 38 C.F.R. § 3.304(f). While acknowledging a diagnosis of PTSD, critical elements of this diagnosis, most fundamentally those concerning the existence of stressors, appear to be based wholly upon statements of history provided by the veteran. Whether the veteran was actually exposed to a stressor in service is a factual determination and the Board is not bound to accept such statements simply because treating medical providers may have done so. The VA outpatient treatment records dated in 1994 reflect an impression of PTSD; however, such impression appears to be based wholly based on claimed symptomatology, and the fact that he was present in the country of Vietnam during the Vietnam War. Notwithstanding this, upon undergoing a VA evaluation in October 1994, the examiner diagnosed mild chronic alcohol abuse, not PTSD. Dr. M. H. B. and Dr. M. B. F. have separately rendered diagnoses of PTSD; however, such diagnoses are based on misleading statements from the veteran, and unverified and unsubstantiated stressors claimed by the veteran. For example, the veteran reported to Dr. M. B. F. that he was in receipt of the Purple Heart and Silver Star due to injuries sustained in service, but as noted there is no documentation to support that the veteran participated in combat, that he sustained any combat related injuries, or that he received combat related medals. Additionally, he did not sustain any combat related injuries. The veteran also reported to Dr. M. B. F. that his medical and military records could not be produced despite seeing much action in combat. The veteran's service personnel records, service medical records, and post- service VA medical records are on file. The only records that have not been associated with the claims folder are VA medical records for the period January 1986 to January 1990, although a record from 1988 is on file. Again, there is no evidence that he was a combat veteran. The diagnosis of PTSD rendered by Dr. M. H. B. is based on an unverified stressor. The veteran told Dr. M. H. B. that he was a combat veteran. The Board is not bound to accept medical opinions that are based on history supplied by the veteran, where that history is unsupported by the evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). It is also noted that a medical opinion diagnosing PTSD does not suffice to verify the occurrence of any claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 396 (1996). As detailed hereinabove, the veteran has claimed three specific stressors occurring during service. Unfortunately, the claimed stressors are not capable of being verified. Pertaining to the claimed stressor relating to the young girl with the grenade that was killed, the Board notes initially that when undergoing a VA psychiatric evaluation in October 1994, he specifically denied killing anyone, including women or children, and reported that a sergeant had killed a young girl with a grenade and that he had almost been brought up on charges for not killing her. However, in a statement submitted nine years later, in October 2003, he reported that in September 1972 he had killed a young girl with a grenade while in Vietnam. Thus, while since 2003 the veteran has consistently reported that he shot a young girl with a grenade, approximately a decade prior he was reporting that it was a sergeant that killed the young girl. In any event, such claimed stressor is not capable of being verified as despite VA requesting more details regarding the claimed stressor, he has not given any information regarding the location of such occurrence, or the convoy unit. Even with this information, it is highly unlikely that the shooting of a young girl with a grenade would be documented in service reports. The veteran was informed that he could submit buddy statements corroborating such incident; however, no such statements have been received to date. With regard to the claimed incident in which the soldier's right leg was blown off, he was put in a body bag but did not actually die, the veteran has not given any information as to when such incident occurred, the name of such soldier, or where such incident occurred. Thus, such claimed incident is not capable of being verified. Likewise, the veteran has claimed that he was in a bunker for three days in the dark; however, he has not given any information as to when or where such incident occurred. As the veteran has not submitted detailed information regarding his claimed stressors, it would be fruitless to submit such claimed stressors to U.S. Army and Joint Services Records Research Center (JSRRC) (formerly known as U.S. Department of the Army's Center for Unit Records Research (CURR)) for verification. The Board in no way intends to impugn the sincerity of the statements made by the veteran; however, his statements that these events occurred are insufficient, by themselves, to establish entitlement to service connection. The Board stresses that mere presence in a combat zone is not sufficient, solely in and of itself, to support a diagnosis of PTSD. A stressor must consist of an event during service. Zarycki v. Brown, 6 Vet. App. 91, 99 (1993). The Board must, therefore, conclude that there is no evidence to substantiate that the veteran's claimed in-service stressors occurred. In conclusion, there is no evidence that the veteran engaged in combat and the only evidence of in-service stressors are contained in the veteran's uncorroborated statements. Thus, there is no probative evidence that the claimed in-service stressors actually occurred. Consequently, absent probative supporting evidence, an essential element for a grant of service connection for PTSD is not established. Furthermore, the Board notes that the post-service diagnoses of PTSD have been rendered based upon the veteran's misleading and uncorroborated accounts as to his in-service experience. A diagnosis of PTSD which is based on an examination which relied upon an unverified history is inadequate. See West v. Brown, 7 Vet. App. 70, 77-78 (1994). In view of the foregoing, because there is no credible supporting evidence of an in-service stressor, and because the diagnosis of PTSD in the record lacks probative value, the Board concludes that the preponderance of the evidence is against the veteran's claim of entitlement to service connection for PTSD. The benefit sought on appeal must, accordingly, be denied. Hearing Loss & Tinnitus Service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See also Hensley v. Brown, 5 Vet. App. 155 (1993). At an August 1970 examination performed for induction purposes, audiometric testing was performed. The audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 15 15 5 20 LEFT 5 5 0 5 15 Service medical records do not reflect any complaints or treatment related to hearing loss or tinnitus. At an October 1973 examination performed for separation purposes, audiometric testing was performed. The audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 5 LEFT 10 10 5 20 Audiometric findings were not reflected at 3000 Hertz. The veteran's ears were clinically evaluated as normal, and no hearing loss or tinnitus is reflected. An October 1973 Report of Medical History completed by the veteran reflects that he checked the 'No' box with regard to 'ear, nose or throat trouble' and 'hearing loss.' In October 1994, the veteran underwent a VA audiological examination. He complained of a history of hearing loss in the left ear, and a history of trauma to the ear, specifically that he ruptured the ear during war. He also complained of tinnitus. The audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT 5 5 15 50 LEFT 20 45 65 85 The average puretone threshold in the right ear was 19, and 54 in the left ear. Speech discrimination scores were 96 percent in the right ear, and 92 percent in the left ear. With regard to tinnitus, the veteran claimed a date of onset in 1972 due to his "eardrums busted." He reported constant tinnitus, mainly in the left ear. In June 2005, the veteran underwent a VA audiological examination. The audiological evaluation showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 45 55 LEFT 40 55 65 75 75 The average puretone threshold in the right ear was 34, and 68 in the left ear. Speech discrimination scores were 100 percent in the right ear, and 88 percent in the left ear. With regard to the right ear, the examiner diagnosed hearing within normal limits 250 to 2000 Hertz sloping to a moderate- to-moderately severe high frequency sensorineural hearing loss, and with regard to the left ear, the examiner diagnosed moderate sloping to severe sensorineural hearing loss. At the May 2005 RO hearing, the veteran testified that during service in 1972, he was "hit," his truck was destroyed, and he busted both of his eardrums and broke his left wrist. He claims he spent 7 to 8 days in the hospital and his ears healed and he guess his hearing came back. In June 2005, another VA examiner provided an opinion with regard to etiology of the veteran's claimed hearing loss and tinnitus. The veteran reported that he was a truck driver during service, and that on one occasion in 1972 an explosion occurred which ruptured his eardrums. Post-service, he reported employment as a truck driver. He reported that he has hauled heavy equipment and has had exposure to heavy equipment subsequent to service. He reported a 20 year history of bilateral progressive hearing loss and a 20 year history of bilateral tinnitus, which is constant and somewhat worse in the left ear than the right ear. The examiner noted review of the claims folder and that hearing loss was recorded as early as 1994. The examiner noted that at that time there was slight asymmetry between the left and right ears, with the left ear being somewhat worse than the right ear. The examiner noted review of the service medical records was negative for hearing loss and/or tinnitus incurred during service. The examiner noted that at separation in 1973, he was noted to have normal audiometric thresholds present at all frequencies recorded. The examiner also noted that the historical data recorded at separation did not indicate complaints of either hearing loss or tinnitus. The examiner stated as follows: Although the veteran feels strongly that his military noise exposure contributed to his hearing loss and tinnitus, this would not be substantiated from my review of service medical records. In fact, the fact that the veteran had normal audiometric thresholds recorded at separation from active service and no complaints of hearing loss or tinnitus noted at separation from active service, would present clear and convincing evidence of rebuttal. It should be noted that hearing loss caused by acoustic trauma occurs at the time of exposure, not years later. It would appear that the veteran's current hearing loss and tinnitus have both occurred subsequent to separation from active service. There has been significant decline in audiometric thresholds in both ears subsequent to separation from service and significant decline since 1994, particularly in the left ear. Since my review of service medical records was negative for hearing loss and/or tinnitus incurred while on active duty, and since the veteran was noted to have normal audiometric thresholds present at separation from service and no complaints of hearing loss or tinnitus noted at separation from active service, it is my opinion that it is less likely than not that the veteran's current hearing loss and tinnitus are related to his military service. The most likely etiology of current hearing loss and tinnitus would be caused by both genetic and environmental factors that have occurred subsequent to separation from active service. Correspondence dated in December 2006 from Dr. J. A. W., an allergy, ear, nose and throat doctor, reflects that the veteran was evaluated in December 2006, and Dr. J. A. W. stated the following: 1. Bilateral sensorineural hearing loss. I think given the pattern of hearing loss, I think the hearing loss is more likely than not related to his previous military exposure. 2. The [veteran] has a significant history of tinnitus in both ears, worse in the left ear which has been present since a motor-vehicle accident with a mortar round in 1972. This is confirmed by exam and by his history. Because of this, I think it is more likely than not related to acoustical trauma as well as the significant traumatic event that occurred during his service. 3. Left-sided conductive hearing loss, most likely consistent with ossicular discontinuity or an ossicular fracture related to his severe trauma that occurred again during his military service which I think is almost certainly related to the trauma suffered in 1972. Upon review of the evidence of record, there is no documented hearing loss or tinnitus in service, no initial complaints of hearing loss or tinnitus until over twenty years after separation from service, and a VA examiner who opined that the veteran's bilateral hearing loss and tinnitus were likely due to genetic and environmental factors that have occurred subsequent to separation from active service, not acoustic trauma experienced during military service. While acknowledging the December 2006 opinion from Dr. J. A. W. pertaining to the veteran's bilateral sensorineural hearing loss and tinnitus, the Board finds that such opinion is entitled to limited probative weight. The veteran has reported an incident of acoustic trauma during service; however, it is clear that Dr. J. A. W. did not review the veteran's service medical records prior to offering an opinion with regard to etiology. Service medical records do not reflect that the veteran sustained any trauma to the ears. It is clear that despite the veteran's contentions otherwise, Dr. J. A. W. was unaware that service medical records do not reflect any complaints of such trauma, nor is he aware that audiological testing conducted on separation in December 1973 did not reflect any hearing loss. The Board is not bound to accept medical opinions that are based on history supplied by the veteran, where that history is unsupported by the evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Moreover, the VA examiner explained that hearing loss caused by acoustic trauma occurs at the time of exposure, not years later. The Board accepts the VA opinion as being the most probative medical evidence on the subject since it was based on a review of all historical records, and provides a detailed rationale for such opinion. See Boggs v. West, 11 Vet. App. 334 (1998). The absence of any evidence of hearing loss and/or tinnitus for over twenty years after discharge from service, or of persistent symptoms of hearing loss and/or tinnitus between service-discharge and 1994 constitutes negative evidence tending to disprove the claim that the veteran developed hearing loss and/or tinnitus as a result of in-service noise exposure, which resulted in chronic disability thereafter. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also 38 C.F.R. § 3.102 (noting that reasonable doubt exists because of an approximate balance of positive and "negative" evidence). The lack of any evidence of continuing hearing loss and/or tinnitus for over two decades between the period of active duty and the evidence showing hearing loss and/or tinnitus is itself evidence which tends to show that no hearing loss or tinnitus was incurred as a result of service. Moreover, there is no medical evidence showing that hearing loss and/or tinnitus manifested itself to a degree of 10 percent or more within one year from the date of separation from active service, and therefore service connection for hearing loss and/or tinnitus may not be presumed to have had its onset in service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). A prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The trier of fact should consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. See Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See also, Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). The "absence" of evidence or "negative" evidence of any injury or hearing loss or tinnitus during service in this case is supported by affirmative evidence which tends to show that no current hearing loss or tinnitus was incurred during that time. Such affirmative evidence consists of the separation examination report which showed no complaints of hearing loss or tinnitus and which indicated a normal clinical audiological evaluation. Although the veteran has asserted that his hearing loss is due to acoustic trauma in service, the fact remains, however, that the veteran did not complain of hearing loss or tinnitus during service, and has not provided any medical evidence, whatsoever, showing treatment for hearing loss or tinnitus until 1994. This is affirmative evidence that the veteran did not sustain hearing loss or tinnitus disability during active duty or that acoustic trauma in service, if any, did not result in chronic hearing loss and/or tinnitus. Thus, the Board concludes that the preponderance of the evidence is against a finding that his current hearing loss and tinnitus are as a result of noise exposure during service. The Board has considered the veteran's own lay statements to the effect that his bilateral hearing loss and tinnitus are causally related to his active service; however, it is noted that there is no medical evidence of record to support such a theory and the veteran has not been shown to have the medical expertise necessary to render such an opinion. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). The negative clinical and documentary evidence post-service for over 20 years is more probative than the remote assertions of the veteran. As noted above, the lack of continuity of treatment may bear in a merits determination on the credibility of the evidence of continuity of symptoms by lay parties. Savage v. Gober, 10 Vet. App. 488, 496 (1997) In reaching this determination, the Board is unable to find such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision for the issues adjudicated by this decision. 38 U.S.C.A. § 5107(b). Congenital Heart Murmur The veteran has claimed entitlement to service connection for congenital heart murmur. As will be discussed in detail below, as a congenital heart murmur is not in and of itself a chronic disability, the Board will also consider whether service connection is warranted for any cardiac disability. An August 1970 examination performed for induction purposes reflects that the veteran's 'lungs and chest' and 'heart' were clinically evaluated as normal. On an August 1970 Report of Medical History completed by the veteran, he checked the 'No' box with regard to 'heart trouble' and did not report a congenital heart murmur. On a September 1970 dental health record, the veteran checked the box for 'heart disease' and stated that he had a congenital heart murmur and an allergy to penicillin. Service medical records do not reflect any complaints or treatment related to the heart. An October 1973 examination performed for separation purposes reflects that the veteran's 'lungs and chest' and 'heart' were clinically evaluated as normal. On an October 1973 Report of Medical History, he checked the 'No' box with regard to 'heart trouble.' VA outpatient treatment records reflect that in June 2003, the veteran had two vessel coronary artery disease status post PTCA with a 70 percent ostial left circumflex lesion, 90 percent long distal left circumflex lesion, 90 percent mid RCA lesion and a normal LAD. He underwent successful stenting of the RCA and left circumflex lesions. Transthoracic echocardiogram showed mildly dilated right atrium and right ventricle but without wall motion abnormalities and preserved left ventricular ejection fraction estimated greater than 50 percent. A January 2004 VA outpatient record reflects a finding of no murmurs. VA outpatient treatment records dated in 2004 through 2006 reflect coronary artery disease asymptomatic, and on appropriate medical management. Thus, while it is clear that the veteran currently has coronary artery disease, the evidence does not suggest that any such disease is due to any claimed congenital heart murmur. As detailed hereinabove, service medical records do not reflect that an in-service examiner detected a heart murmur, but the veteran reported a congenital heart murmur at a dental visit during service. Service medical records, however, do not reflect any complaints or findings of a cardiac disability. While acknowledging that a murmur may, or may not, be a manifestation of a chronic disorder, it is not itself disabling. As noted, service medical records do not reflect any identifiable pathology of heart disease. Decades after separation from service, VA treatment records reflect a diagnosis of coronary artery disease. But the evidence is clear that a cardiac disability was not shown in service, nor within a year of separation from service. There was no identifiable pathology of the heart shown at any time during the veteran's period of service, nor for many years after separation from service. The veteran has not otherwise submitted any evidence to support his claim that he has a cardiac disability that his related to service. The Board acknowledges the veteran's belief that his current coronary artery disease is related to service; however, although the veteran is competent to report symptoms he experiences, he is not qualified to render an opinion as to etiology of this disorder. See Espiritu v, Derwinski, 2 Vet. App. 492, 495 (1992). It is noted that the RO did not provide a VA examiner to review the claims file for a nexus opinion for this service connection claim; however, such is not required in order to make a final adjudication. McLendon v. Nicholson, 20 Vet. App. 79 (2006), states, that in disability compensation (service connection) claims, VA must provide a medical examination [for a nexus opinion, as applicable] when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Simply stated, the standards of McLendon are not met in this case. The evidence does not establish that the veteran suffered "an event, injury or disease in service," with regard to his claimed cardiac disability, so it is not necessary to obtain a VA medical opinion with regard to etiology. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In other words, absent such evidence, the Board finds that it is unnecessary to require the veteran to report for a VA medical examination or to ask a medical expert to review the record because any examination report or medical opinion could not provide competent evidence of the incurrence of a cardiac disability in service. Moreover, given the absence of any competent evidence of the claimed post-service disability until decades after service, any current opinion provided at this point would be no more than speculative. See 38 C.F.R. § 3.102 (a finding of service connection may not be based on a resort to speculation or even remote possibility). In summary, as a cardiac disability was not shown in service or for many years thereafter, and because there is no evidence of record suggesting that the veteran's cardiac disability is related to his active service, the Board finds that the preponderance of the evidence is against the veteran's claim of service connection for a congenital heart murmur, to include cardiac disability. Hypertension The veteran has specifically claimed entitlement to service connection for hypertension as secondary to PTSD. Initially, the Board notes that the veteran's service medical records do not reflect any diagnosis of hypertension. The October 1973 Report of Medical Examination reflects a blood pressure reading of 120/60. On the October 1973 Report of Medical History, the veteran checked the 'Don't Know' box pertaining to 'high or low blood pressure;' however, as noted the separation examination does not reflect an objective finding of low or high blood pressure. A post-service VA outpatient treatment record dated in June 2003 reflects a diagnosis of hypertension. The Board notes that the veteran has claimed that he initially sought VA treatment for hypertension in 1986. Even if the Board were to accept that he was treated for hypertension as early as 1986, this still constitutes a 13 year period between separation from service and a diagnosis. There is no medical evidence to support that such disability was due to active service or any incident therein. Due to the finding that service connection for PTSD is not warranted, service connection on a secondary basis for hypertension is also not warranted. See 38 C.F.R. § 3.310. Anxiety The veteran has specifically claimed entitlement to service connection for anxiety as secondary to PTSD. Initially, the Board notes that the veteran's service medical records do not reflect any diagnosis of anxiety or any mental illness or condition. Service medical records do not reflect any complaints or treatment for anxiety. The October 1973 Report of Medical Examination reflects that his psychiatric state was clinically evaluated as normal. On the October 1973 Report of Medical History, the veteran checked the 'No' box pertaining to 'depression or excessive worry' or 'nervous trouble of any sort.' While post-service medical records do not reflect a specific diagnosis of anxiety, such records do reflect a diagnosis of depression. However, there is no medical evidence to support that such disability was due to active service or any incident therein. Due to the finding that service connection for PTSD is not warranted, service connection on a secondary basis for anxiety is also not warranted. See 38 C.F.R. § 3.310. ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for PTSD; to this extent, the appeal is granted. New and material evidence has been received to reopen the claim of entitlement to service connection for bilateral hearing loss disability; to this extent, the appeal is granted. New and material evidence has been received to reopen the claim of entitlement to service connection for tinnitus disability; to this extent, the appeal is granted. Entitlement to service connection for PTSD is denied. Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to service connection for tinnitus disability is denied. Entitlement to service connection for congenital heart murmur and cardiac disability is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for anxiety is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs