Citation Nr: 1225344 Decision Date: 07/20/12 Archive Date: 07/30/12 DOCKET NO. 08-21 819 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a heart disorder, including as due to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for the residuals of a cerebrovascular accident (stroke), including as due to service-connected PTSD. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD William Alan Nelson II, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from December 1951 to December 1955. This case comes before the Board of Veterans' Appeals (Board) on appeal of a September 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The issues of service connection for a heart disorder and residuals of a stroke were previously remanded by the Board in March 2011 for further procedural and evidentiary development of requesting outstanding post-service VA and private treatment records, providing the Veteran with proper notice for his claims, and obtaining medical nexus opinions for heart disorder and residuals of a stroke. This was accomplished, and the claims were readjudicated in an April 2012 supplemental statement of the case (SSOC). For this reason, the Board concludes that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims on appeal has been accomplished. 2. The Veteran did not sustain a heart injury or disease in service. 3. Heart disorder symptoms were not chronic in service. 4. Heart disorder symptoms have not been continuous since service separation. 5. The Veteran's heart disorder is not related to active service. 6. The Veteran's heart disorder is not causally related to or permanently worsened by service-connected disabilities. 7. The Veteran did not sustain a stroke in service. 8. Stroke symptoms were not chronic in service. 9. Stroke symptoms have not been continuous since service separation. 10. There are no residuals of a stroke related to active service. 11. There are no residuals of a stroke causally related to or permanently worsened by service-connected disabilities. CONCLUSIONS OF LAW 1. A heart disorder was not incurred in or aggravated by active service and was not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.3.07, 3.309, 3.310 (2011). 2. Residuals of a stroke were not incurred in or aggravated by active service and are not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.3.07, 3.309, 3.310 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2011). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely June 2006 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording VA medical examinations in December 2007, May 2011, and July 2011. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions and findings obtained in this case are adequate. The VA nexus opinions provided consider all of the pertinent evidence of record, to include the statements of the Veteran, and provide a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues of service connection for a heart disorder and residuals of a stroke has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording VA examinations. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, VA examinations, post-service VA and private treatment records, and the Veteran's statements. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). 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). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as cardiovascular-renal disease and brain hemorrhage, to a degree of 10 percent or more within one year from separation from service, such diseases may 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. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr, 21 Vet. App. 303; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan, 451 F.3d at 1336 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection for Heart Disorder The Veteran contends that he has a heart disorder that began during active service and also that his heart disorder is due to service-connected PTSD. During the current claim, the Veteran also asserted that he has had continuous heart disorder symptoms since service separation. The Board finds that the weight of the evidence demonstrates that the Veteran did not sustain a heart injury or disease in service, and did not experience chronic heart disorder symptoms in service. Service treatment records are negative for any complaints or treatment for a heart injury or disease. The evidence in this case includes the clinical evaluation at the December 1955 service separation examination that found normal "heart." 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). The Board next finds that the weight of the evidence demonstrates that heart disorder symptoms have not been continuous since service separation. Following service separation in December 1955, the evidence of record shows no findings, diagnosis, or treatment for any heart disorder until 2004. The absence of post-service findings, diagnosis, or treatment after service for 49 years until 2004 is one factor, considered in addition to the other factors stated in this decision, that tends to weigh against a finding of either chronic heart disorder symptoms in service or continuous symptoms of a heart disorder after service separation. See Buchanan, 451 F.3d at 1337 (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor that tends to weigh against a claim for service connection). While the Veteran is competent to state that he had heart disorder symptoms at any time, including in service, the Board finds that the Veteran's more recent assertions of heart disorder symptoms in service and continuous heart disorder symptoms since service, made in the context of the April 2006 claim of service connection (disability compensation) for a heart disorder, are outweighed by the other, more contemporaneous, lay and medical evidence of record, and are not credible. See Charles v. Principi, 16 Vet. App. 370 (2002). The recent statements of chronic heart disorder symptoms in service and continuous post-service heart disorder symptoms are inconsistent with the service treatment record evidence and the findings at the service separation examination in December 1955. The Veteran's recent statements of chronic heart symptoms in service and continuous heart disorder symptoms are also inconsistent with the Veteran's own histories and the findings in VA and private treatment records. VA treatment records dated from July 2004 to November 2005 and March 2009 to June 2011 do not reflect any report of an in-service heart injury or disease, chronic heart disorder symptoms in service, or continuous heart disorder symptoms since service separation. Private treatment records dated from December 1996 to June 2005 do not reflect any report of an in-service heart injury or disease, chronic heart disorder symptoms in service, or continuous heart disorder symptoms since service separation. For treatment, the Veteran would be expected to give a full and accurate history to get good treatment. In none of these examinations for treatment does the Veteran mention a heart injury in service, chronic heart disorder symptoms in service, or continuous heart disorder symptoms since service. See Cartright, 2 Vet. App. at 25; Pond v. West, 12 Vet. App. 341 (1991). Other evidence tending to show that heart disorder symptoms have not been continuous since service separation include the August 2001 private treatment record, where the Veteran reported chest pain; however, the private examiner reported no cardiovascular symptoms and heart with normal rate and rhythm and no murmurs, gallups, or rubs. In a June 2003 private treatment record, the Veteran reported no cardiovascular symptoms and the private examiner reported heart with normal rate and rhythm and no murmurs, gallups, or rubs. In a June 2004 private treatment record, the Veteran reported no cardiovascular symptoms and the private examiner reported heart with normal rate and rhythm and no murmurs, gallups, or rubs. The private examiner also reported that the Veteran had a stress test in 1999 which was normal. In a July 2004 VA treatment record, the VA examiner reported heart with normal rate and rhythm and no murmurs, gallups, or rubs. In a March 2005 VA treatment record, the Veteran reported chest pain only for the last four months. In a December 2007 VA medical examination, the VA examiner diagnosed stable coronary artery disease and reported no myocardial infarction or hypertension, and reported heart with normal rate and rhythm and no murmurs. The Board finds that the statements definitively indicating a lack of continuity of heart disorder symptomatology made to health care professionals are more credible than the more ambivalent statements regarding a heart disorder made in support of an appeal for compensation benefits. See Cartright, 2 Vet. App. at 25; Pond (interest may affect the credibility of testimony). The Board also notes that the Veteran's service connection claims to VA for other disabilities in July 1988 and September 2005 did not include or mention a heart disorder; the first time the Veteran had asserted a heart injury or disease during service and continuous heart disorder symptoms since service was in June 2006. See Cromer v. Nicholson, 19 Vet. App. 215 (2005) (upheld Board's denial of service connection and finding that a veteran's recent post-service account of in-service events was not credible because the veteran had previously given other histories and theories that did not mention the alleged in-service event, and first "came up with the story" years after service and in connection with the compensation claim). The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology (Savage v. Gober, 10 Vet. App. 488, 496 (1997)); however, here, the Veteran filed claims for service connection, but did not mention heart disorder symptoms at that time. This suggests to the Board that there was no pertinent heart disorder symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In this case, the Veteran demonstrated in 1988 and 2005 that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for a heart disorder at the time of the July 1988 and September 2005 claims, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of the lack of heart disorder symptomatology at the time he filed the claims. The Board further finds that the weight of the evidence demonstrates that the Veteran's currently diagnosed heart disability is not related to his active service. In a July 2011 VA opinion, the VA examiner opined that the Veteran's heart disorder was less likely than not (less than 50 percent probability) related to service. The VA examiner reasoned that the Veteran did not exhibit any cardiac condition in service and that there was no heart disorder symptoms for many years after service until 2004. The VA examiner further reasoned that the only risk factor for heart disease was hypercholesterolemia, which was treated and stable. The weight of the competent evidence demonstrates no relationship between the Veteran's current heart disorder and his military service, including no credible evidence of continuity of symptomatology of a heart disorder which would serve either as a nexus to service or as the factual basis for a medical nexus opinion. On the question of relationship of current heart disability to service, the only probative nexus opinion on file, in July 2011, weighs against the claim. The July 2011 VA opinion is competent and probative medical evidence because it is factually accurate and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence. The VA examiner reviewed the claims file, including the Veteran's own reported histories and complaints, and fully articulated the opinion; therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against a finding of relationship of a heart disorder to service. The Veteran is also claiming that his heart disorder is the direct result of his service-connected disabilities, specifically service-connected PTSD. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17. The Veteran is service connected for PTSD. In a June 2005 private medical examination, the Veteran was diagnosed with coronary artery disease (CAD), status post stents with hypertension and hyperlipidemia. The Board finds that the weight of the evidence demonstrates that the Veteran's heart disorder is not proximately due to or aggravated by the service-connected PTSD. In the July 2011 VA medical opinion, which weighs against the Veteran's claim, the VA examiner opined that the Veteran's heart disorder was less likely than not related to the Veteran's service-connected PTSD. The VA examiner reasoned that, after review of the current peer reviewed medical literature, there is not a physiological nexus between PTSD and ischemic heart disease. For these reasons, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a heart disorder, including as secondary to a service-connected disability, and outweighs the Veteran's more recent contentions regarding in-service chronic heart disorder symptoms and post-service heart disorder symptoms. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Residuals of a Stroke The Veteran contends that he has residuals of a stroke that began during active service and also that his residuals of a stroke are due to service-connected PTSD. During the current claim, the Veteran also asserted that he has had continuous stroke symptoms since service separation. The Board finds that the weight of the evidence demonstrates that the Veteran did not sustain a stroke in service, and did not experience chronic stroke symptoms in service. Service treatment records are negative for any complaints or treatment for a stroke. The evidence in this case includes the clinical evaluation at the December 1955 service separation examination that found normal "vascular system." 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). The Board next finds that the weight of the evidence demonstrates that stroke symptoms have not been continuous since service separation. Following service separation in December 1955, the evidence of record shows no findings, diagnosis, or treatment for any stroke until 2008. The July 2008 statement of Dr. Fisch indicated that MRI testing of the brain showed an area consistent with stroke or injury. However, on VA examination in May 2011, the Veteran denied a history of transient ischemic attack (TIA) or cerebrovascular accident (CVA). The absence of post-service findings, diagnosis, or treatment after service for 53 years until 2008 is one factor, considered in addition to the other factors stated in this decision, that tends to weigh against a finding of either chronic stroke symptoms in service or continuous symptoms of a stroke after service separation. See Buchanan, 451 F.3d at 1337 (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also Maxson, 230 F.3d at 1333 (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor that tends to weigh against a claim for service connection). While the Veteran is competent to state that he had stroke symptoms at any time, including in service, the Board finds that the Veteran's more recent assertions of stroke symptoms in service and continuous stroke symptoms since service, made in the context of the April 2006 claim of service connection (disability compensation) for residuals of a stroke, are outweighed by the other, more contemporaneous, lay and medical evidence of record, and are not credible. See Charles. The recent statements of chronic stroke symptoms in service and continuous post-service stroke symptoms are inconsistent with the service treatment record evidence and the findings at the service separation examination in December 1955. The Veteran's recent statements of chronic stroke symptoms in service and continuous stroke symptoms since service are also inconsistent with the Veteran's own histories and the findings in VA and private treatment records. VA treatment records dated from July 2004 to November 2005 and March 2009 to June 2011 do not reflect any report of an in-service stroke, chronic stroke symptoms in service, or continuous stroke symptoms since service separation. Private treatment records dated from December 1996 to June 2005 do not reflect any report of an in-service stroke, chronic stroke symptoms in service, or continuous stroke symptoms since service separation. For treatment, the Veteran would be expected to give a full and accurate history to get good treatment. In none of these examinations for treatment does the Veteran mention a stroke in service, chronic stroke symptoms in service, or continuous stroke symptoms since service. See Cartright, 2 Vet. App. at 25; Pond. Other evidence tending to show that stroke symptoms have not been continuous since service separation include a December 2007 VA medical examination which shows that the VA examiner diagnosed stable coronary artery disease and reported no myocardial infarction or stroke and the May 2011 VA examination during which the Veteran denied a history of strokes or transient ischemic attacks and the examiner concluded that there was no diagnosis of TIA or CVA. The Board finds that the statements definitively indicating a lack of continuity of symptomatology related to the claimed stroke made to health care professionals are more credible than the more ambivalent statements regarding a stroke disorder made in support of an appeal for compensation benefits. See Cartright, 2 Vet. App. at 25; Pond (interest may affect the credibility of testimony). The Board also notes that the Veteran's service connection claims to VA for other disabilities in July 1988 and September 2005 did not include or mention residuals of a stroke; the first time the Veteran had asserted a stroke during service and continuous stroke symptoms since service was in June 2006. See Cromer (upheld Board's denial of service connection and finding that a veteran's recent post-service account of in-service events was not credible because the veteran had previously given other histories and theories that did not mention the alleged in-service event, and first "came up with the story" years after service and in connection with the compensation claim). The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology (Savage v. Gober, 10 Vet. App. 488, 496 (1997)); however, here, the Veteran filed claims for service connection, but did not mention stroke symptoms at that time. This suggests to the Board that there was no pertinent stroke symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In this case, the Veteran demonstrated in 1988 and 2005 that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for residuals of a stroke at the time of the July 1988 and September 2005 claims, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of the lack of stroke symptomatology at the time he filed the claims. The Board further finds that the weight of the evidence is against a finding that the Veteran has residuals of a stroke related to his active service. In a July 2008 private opinion, the private examiner opined that it was "possible" that the Veteran suffered a stroke during active duty service. As noted above, in the May 2011 VA opinion, the Veteran denied a history of strokes or transient ischemic attacks and the examiner concluded that there was no diagnosis of TIA or CVA. The Board finds that the July 2008 private opinion is of little probative value. The July 2008 private examiner opined that it was "possible" that the Veteran suffered a stroke during active duty service. The Board notes that statements like this from doctors are, for all intents and purposes, inconclusive as to the origin of a disability. See Warren, 6 Vet. App. at 6; Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). Opinions like this are of no probative value for or against the claim because service connection may not be based on speculation or remote possibility. See generally Bloom (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty); see also 38 C.F.R. § 3.102 (2011) (when considering application of the benefit-of-the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). The weight of the competent evidence demonstrates no relationship between the claimed residuals of a stroke and the Veteran's military service, including no credible evidence of continuity of symptomatology of a stroke which would serve either as a nexus to service or as the factual basis for a medical nexus opinion. On the question of relationship of current stroke disability to service, the only probative nexus opinion on file, in May 2011, weighs against the claim. The May 2011 VA opinion is competent and probative medical evidence because it is factually accurate and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence. The VA examiner reviewed the claims file, including the Veteran's own reported histories and complaints, and fully articulated the opinion; therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against a finding of relationship of residuals of a stroke to service. The Veteran is also claiming that his residuals of a stroke are the direct result of his service-connected disabilities, specifically service-connected PTSD. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17. The Veteran is service connected for PTSD. In a June 2008 private medical statement notes a history of a stroke but does not include an opinion linking a stroke to PTSD. The Board finds that the weight of the evidence demonstrates that the Veteran's residuals of a stroke are not proximately due to or aggravated by the service-connected PTSD. In the May and July 2011 VA medical opinions, which weigh against the Veteran's claim, the VA examiner opined that the Veteran did not have a current diagnosis of residuals of a stroke and it was further concluded that heart disease was less likely than not related to the Veteran's service-connected PTSD. The VA examiner reasoned that, after review of the current peer reviewed medical literature, there is not a physiological nexus between PTSD and ischemic heart disease. For these reasons, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for residuals of a stroke, including as secondary to a service-connected disability, and outweighs the Veteran's more recent contentions regarding in-service chronic stroke symptoms and continuous post-service stroke symptoms. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Service connection for a heart disorder is denied. Service connection for residuals of a stroke is denied. ____________________________________________ K. J. Alibrando Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs