Citation Nr: 1237308 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 10-09 082 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for an acquired psychiatric disorder, to include mood disorder and posttraumatic stress disorder. 4. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 5. Entitlement to service connection for coronary artery disease, claimed as a heart disorder, to include as being secondary to chemical dioxin exposure. 6. Entitlement service connection for hypertension, to include as being secondary to chemical dioxin exposure. 7. Entitlement to service connection for irritable bowel syndrome (IBS). 8. Entitlement to service connection for Sjoren's syndrome. 9. Whether new and material evidence has been submitted sufficient to reopen the appellant's claim for entitlement to service connection for a left knee disability, to include chondromalacia of the left knee, and, if so, whether service connection may be granted. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Patrick J. Costello, Counsel INTRODUCTION The appellant served on active duty in the United States Navy from June 1968 to December 1973. This appeal to the Board of Veterans' Appeals, hereinafter the Board, arises from rating decision of March 2009 by the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA). Subsequent to the rating action, the appellant presented testimony before the undersigned Veterans Law Judge (VLJ) via a videoconference hearing in September 2012; a transcript of that hearing was produced and has been included in the claims folder for review. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted that basis of the prior determination and noted the elements of the claim that were lacking to substantiate the claim for benefits. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, the appellant has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the appellant, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. The Board notes that, in the March 2009 rating decision and the subsequent statement of the case, the RO characterized the issue to reopen the claim of service connection for a left knee disability as that of entitlement to service connection, and finds that, by its silence, the RO apparently conceded that the appellant had submitted sufficient evidence to reopen the claim of entitlement to service connection, which was previously denied in a February 1992 rating decision. However, the Court has held that, in a matter such as this, the Board has a legal duty to consider the issue of whether new and material evidence has been submitted to reopen the claim, regardless of the RO's actions. See Barnett v. Brown, 8 Vet. App. 1 (1995). Furthermore, if the Board finds that new and material evidence has not been submitted, it is unlawful for the Board to reopen the claim. See McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). Therefore, the issue currently before the Board is whether new and material evidence has been received to reopen a claim of entitlement to service connection for a left knee disability and has been recharacterized as such on the front page of this action. The issues of entitlement to service connection for disabilities of the knees, a mental disorder, COPD, coronary heart disease and hypertension, IBS, and Sjoren's syndrome are addressed in the REMAND portion of the decision below and they are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACTS 1. In a February 1992 rating action, the RO denied the appellant claim for entitlement to service connection for a left knee disability. The appellant did not request reconsideration nor did he appeal the RO's action. Thus, the February 1992 rating action is final. 2. The evidence received since the RO's rating action of February 1992 is not duplicative or cumulative of evidence previously of record and does raise a reasonable possibility of sustaining the appellant's claim for entitlement to service connection for a left knee disability. 3. The appellant has been diagnosed as suffering from tinnitus. 4. The medical evidence of record is inconclusive as to whether the appellant's inservice noise exposure contributed to his current tinnitus. 5. The appellant has credibly testified that he experienced tinnitus in service which continued after his discharge. CONCLUSIONS OF LAW 1. The February 1992 RO decision that denied the appellant's claim for entitlement to service connection for a left knee disability is final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1991); currently 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 2. New and material evidence has been submitted, and the claim for entitlement to service connection for a left knee disability has been reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (a) (2012). 3. Resolving all reasonable doubt in the appellant's favor, the appellant's tinnitus was incurred during active military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1310, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Also, the Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. New and Material Evidence - Left Knee The appellant comes before the Board requesting that his claim for entitlement to service connection be reopened and that a decision be issued on the merits. A. The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). In this case, the Board is reopening the claim of entitlement to service connection for a left knee disability. Assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. B. New and Material Evidence As will be detailed below, the appellant's claims for entitlement to service connection for a disability of the left knee has been the subject of an adverse prior final decision. As a result, service connection for this disorder may now be considered on the merits only if new and material evidence has been received since the time of the last final adjudications. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). For claims to reopen, evidence is considered "new" if it was not previously submitted to agency decision makers. "Material" evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 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. 38 C.F.R. § 3.156(a) (2012). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Court has clarified that, with respect to the issue of materiality, the newly presented evidence need not be probative of all the elements required to award the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Additionally, the evidence necessary to meet the criteria of raising a reasonable possibility of substantiating the claim should be interpreted as enabling rather than precluding reopening. Shade v. Shinseki, 24 Vet. App. 110 (2010). C. Analysis The record reflects that in November 1991, the appellant submitted a claim to the VA asking that service connection be granted for a left knee disability. In this application for benefits, the appellant merely stated that he now suffered from a left knee disability that he believed began in or was caused by his military service. To support his claim, the appellant proffered private medical records showing treatment for said knee condition. Also of record were the appellant's service medical treatment records. Upon review of evidence of record, the RO concluded that service connection could not be granted because the service treatment records did not show complaints of a left knee disability while he was in service and there was a lack of continuity of symptoms or treatment following service. The RO effectuated that conclusion through the publication of a rating action in February 1992. The appellant was notified of that action but he did not seek reconsideration nor did he appeal to the Board. Hence, the February 1992 rating action became final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1991); currently 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). Approximately sixteen years later, the appellant came again to the VA asking that service connection be granted for a left knee disability. To support his claim, the appellant proffered statements written by himself and his former spouse along with miscellaneous medical records. Of particular note was the statement provided by the appellant's former spouse - in that statement she stated that the appellant had difficulties with his left knee both in service and after service. She further remarked that after service, the appellant needed to have the left knee operated thereon. Subsequent to that statement, the appellant underwent a VA orthopedic examination. Upon completion of the examination, the examiner suggested that the left knee disability began in or was caused by service. However, shortly thereafter, the examiner changed his opinion and found that the left knee disability did not begin in service and was not the result of the appellant's military service. The examination report along with available medical records and the statements provided by the appellant and his former spouse were reviewed by the RO which, in turn, issued a rating action in March 2009. In essence, the RO found that the appellant had not submitted evidence in support of his claim and as such, his claim for benefits was denied. The evidence submitted in connection with the appellant's current claim includes multiple VA medical treatment records, written statements from the appellant and his former wife, and his testimony before the Board. As suggested earlier, of interest are the statements provided by the appellant and his former wife where there was a description of the condition and the treatment received by the appellant since service. As this record is clearly new and offers a potential link of a current disability with service, it does relate to previously unestablished facts necessary to substantiate the claim. Accordingly, the Board concludes that the appellant has submitted evidence that is new and material, and the issue of entitlement to service connection for a left knee disability is reopened. Since the claim is reopened, the Board must address the merits of the appellant's claim. However, before proceeding to a decision on the merits, it is the Board's opinion that further development is necessary. See 38 U.S.C.A. § 5103A (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(c) (2012). Hence, the claim will be remanded for the purpose of obtaining additional medical evidence. II. Service Connection - Tinnitus A. Veterans Claims Assistance Act of 2000 (VCAA) Before addressing the merits of the appellant's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2012). However, since this portion of the decision represents a complete grant of the benefits sought on appeal, no further discussion of the VA's "duty to notify" and "duty to assist" obligations is necessary since no prejudice to the appellant can result. B. Laws and Regulations As indicated on the front page of this action, the appellant has come before the VA asking that service connection be granted for his and tinnitus. He has claimed that as a result of his being aboard three different ships in the Navy, he was repeatedly exposed to loud acoustic noises. He has averred that since service, he has experienced ringing in the ears. The RO has denied his claim for benefits and he has appealed to the Board for review. Under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when: (1) a chronic disease manifests itself and is identified as such in service (or within the presumption period under 38 C.F.R. § 3.307) and the service member presently has the same condition; or (2) a disease manifests itself during service (or during the presumptive period), but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the service member's present condition. Savage v Gober, 10 Vet. App. 488, 495-98 (1997). To grant service connection, it is required that the evidence shows the existence of a current disability, an in-service disease or injury, and a link between the disability and the in-service disease or injury. Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the United States Court of Appeals for the Federal Circuit, which has stated that ". . . a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Moreover, service connection connotes many factors, but basically, it means that the facts, as shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service. A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease in service. See Pond v. West, 12 Vet. App. 341 (1999); Watson v. Brown, 4 Vet. App. 309, 314 (1993). C. Facts and Analysis As noted, the appellant has claimed that he now suffers from tinnitus, that it began many years ago, and that it is his opinion that his tinnitus is due to or the result of noise exposure he experienced while on active duty. A review of the service medical records fails to show any complaints involving tinnitus. It is not until the appellant filed this claim for benefits that the appellant indicated that he was suffering from ringing in the ears. In conjunction with his claim for benefits, the appellant underwent a VA Audiological Examination in May 2010. During that exam, the appellant indicated that he began noticing constant ringing in his ears shortly after he was released from active duty. The examiner subsequently diagnosed the appellant as having tinnitus but he did not provide an etiological opinion concerning the disability. A second examination was performed in September 2011. At that time, the examiner wrote that since the appellant did not notice constant ringing in the ears until after service, the complained of tinnitus was not service related or caused by the appellant's naval service. In sum, the probative evidence is as follows: The appellant experienced acoustic trauma with on active duty in the US Navy. The appellant did not experience acoustic trauma after service. The appellant has indicated that he has suffered from tinnitus since service. A VA audiologist has merely stated that it the appellant's tinnitus was not related to any acoustic trauma while in service but has not provided any explanation to said hypothesis. It is noted that the same audiologist has concluded that the appellant's bilateral hearing loss was due to inservice loud noise exposure. In determining whether evidence submitted by a veteran is credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The service member's statements that he has proffered during the course of this appeal have not been contradictory. Moreover, since he filed his claim, his recitation of the symptoms produced by his tinnitus, and how long the condition has bothered him, has remained consistent. The Board finds that his written and testimonial evidence is credible, probative, and it adds weight to the overall claim. See, e.g., Struck v. Brown, 9 Vet. App. 145, 155-156 (1996); also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, 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 v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the Board finds that the appellant's assertions concerning his tinnitus are consistent with his military service. In the statements provided to the VA, the appellant has asserted that he was exposed to naval ship gunfire when he worked on the bridge of the ship and when he was billeted below the large weapons pieces. The service records confirm that the appellant was attached to an ordnance unit and has a military occupational specialty that would have exposed the appellant to ordnance or large weapons fire. He further reported that he did not realize that he was experiencing tinnitus until after he left the service. His statements are credible and supported by the later diagnosis of tinnitus. The Board acknowledges that a VA audiologist has hypothesized that the appellant's diagnosed tinnitus was not caused by in-service noise exposure. With regards to this piece of medical evidence, the Board must weigh the credibility and probative value of the medical opinion, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In the case of Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), the Court held that a claims file review, as it pertains to obtaining an overview of an appellant's medical history, is not a requirement for private medical opinions. A review of the claims file by a VA examiner, without more, does not automatically render the VA examiner's opinion competent or persuasive since the claims file is a tool to assist in familiarity for the physician with the claims file, and conversely a private medical opinion may not be discounted solely because the opining clinician did not review the claims file as there are other means by which a physician can become aware of critical medical facts, such as a history of treating the appellant for an extended period of time and/or reviewing pertinent medical literature. The relevant focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion. Thus, when VA refers to facts obtained from review of the claims file as a basis for crediting one expert opinion over another, it is incumbent upon VA to point out those facts and explain why they were necessary or important in forming the appropriate medical judgment. Certainly, the particular medical information contained in a claims file may have significance to the process of formulating a medically valid and well-reasoned opinion. The Court further held that a medical opinion that contains only data and conclusions is not entitled to any weight and a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes is derived. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In sum, in Nieves-Rodriguez, the Court indicated that it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion. In this instance, the VA audiologist reasoned that the appellant's tinnitus was not related to service. However, that same individual failed to provide any reasoning with his hypothesis nor did he discuss the appellant's assertions concerning chronicity. Upon further review, and because the lack of clarity contained in the examination report, the Board assigns limited weight to the examiner's opinion as it is not well-reasoned or consistent with other evidence of record. In other words, the examiner was equivocal, vague, and ambiguous with his opinion. Accordingly, the Board attaches very little probative value to the VA opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.). Nevertheless, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has further clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Information in the service records supports the appellant's contentions and his assertions concerning his noise exposure are consistent with service. The Board further believes the consistent written and spoken statements and as such, the statements are competent to show in-service occurrence because the condition itself (ringing in the ears) is capable of lay observation. Again, see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (rejecting view lay person is not competent to provide testimony regarding nexus); see also Barr v. Nicholson, 21 Vet. App. 303, 307-09 (2007) (holding that medical evidence is not always required to establish the elements of in-service incurrence and nexus); Gutierrez v. Principi, 19 Vet. App. 1, at 8-9 (2004) (lay persons are competent to report objective signs of illness in Persian Gulf War illness cases). When, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2010); see also 38 C.F.R. § 3.102 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." The Court pointed out in Gilbert that under the benefit of the doubt doctrine established by Congress, when the evidence is in relative equipoise, the law dictates that the service member prevails. In view of the foregoing, the Board finds that the evidence is, at least, in equipoise. The Board finds that the probative evidence is in equipoise as to the date of onset of the current tinnitus. There is no definitive medical opinion on file as to the etiology of the current tinnitus, but the Board finds that, due to the self-reported nature of tinnitus, and a liberal application of the provisions pertaining to continuity of symptoms, none is needed. Because the evidence is at least in equipoise, and since the appellant is supposed to be afforded the benefit-of- the-doubt, the Board concludes that the appellant's tinnitus is the result of noise exposure he endured while he was on active duty in the US Navy. Therefore, service connection is granted. ORDER New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for a disability of the left knee; to this extent only, the appeal is granted. Entitlement to service connection for tinnitus is granted. REMAND As reported above, the appellant proffered testimony before the undersigned VLJ. He reported that he had been awarded Social Security Administration (SSA) and then he intimated that those benefits had been awarded for disabilities that he was now seeking service connection. He averred that those records might have information relevant to the claims now before the Board. The Court has held that VA must obtain SSA decisions and records which may have a bearing on the appellant's claims. Waddell v. Brown, 5 Vet. App. 454 (1993); Clarkson v. Brown, 4 Vet. App. 565 (1993); Shoemaker v. Brown, 3 Vet. App. 519 (1993). Moreover, the Court has found that, "[i]n the context of the duty to assist in obtaining records, the relevance of the documents cannot be known with certainty before they are obtained." Hyatt v. Nicholson, 21 Vet. App. 390 (2007). In this instance, the appellant has merely claimed that he is in receipt of SSA disability benefits; he has not been very specific as why SSA is providing SSA benefits nor has he indicated what disabilities entitle him to SSA payments. He has only made insinuations. Nevertheless, there is no indication that any effort has been made to secure the SSA decision awarding such benefits or any associated medical records. Hence, in keeping with the Board's duty to assist the appellant with his claim, the claim must be remanded so that the SSA decision and medical records may be obtained and incorporated into the claims file. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2011). Also, because the claim is being returned for additional development, copies of any available VA and private medical records subsequent to 2008 should be obtained and incorporated in the claims file. It is important to note that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of that claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Hence, these private and VA treatment records should be associated with the claims file. Also, the VA's duty to assist the appellant in the development of his or her claim includes the providing of a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The record reflects that a VA examiner has not commented on the assertions earnestly made by the appellant; i.e., that he now suffers from conditions he believes are service-related and was caused by his service-connected disabilities. While the appellant did undergo a few medical examinations in 2010 and 2011, those examinations were performed by examiners who did not have complete files before them. That is, they did not have the appellant's SSA records or all of his post-service treatment records. A thorough and contemporaneous medical examination that takes into account the records of prior medical treatment (the complete claims folder) so that the disability evaluations will be a fully informed one should be accomplished. See Hyder v. Derwinski, 1 Vet. App. 221 (1991); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding the Board is prohibited from relying on its own unsubstantiated medical judgment in the resolution of claims). Based upon the evidentiary record in the instant case, or the lack thereof, and in light of the applicable provisions of the VCAA, Miller v. West, 11 Vet. App. 345 (1998), Gabrielson v. Brown, 7 Vet. App. 36 (1994), and, most specifically, Barr v. Nicholson, 21 Vet. App. 303 (2007), it is the Board's opinion that such examinations should be afforded the appellant before the Board issues a determination on the merits of his claim. The action identified herein is consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). However, identification of specific action requested on remand does not relieve the RO/AMC of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the action requested above, the RO/AMC should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claim on appeal. Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC should send the appellant corrective VCAA notice under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2011) and 38 C.F.R. § 3.159 (2012) for the issues now on appeal including an explanation of how to prevail on claims involving secondary service-connection and chemical dioxin exposure. The appellant should also be invited to submit any pertinent evidence in his possession. The RO/AMC must explain the type of evidence that is the appellant's ultimate responsibility to submit. A copy of all correspondence to the appellant should be included in the claims folder for review. 2. The AMC/RO should contact the appellant and ask that he identify all sources of medical treatment received since the appellant left the US Navy for all of the disabilities now on appeal (right knee disability, left knee disability, an acquired psychiatric disorder, COPD, coronary artery disease, hypertension, IBS, and Sjoren's syndrome), and to furnish signed authorizations for release to the VA of private medical records in connection with each non-VA source identified. Copies of the medical records from all sources, including VA records, (not already in the claims folder) should then be requested. All records obtained should be added to the claims folder. If requests for any treatment records are not successful, the AMC/RO should inform the appellant of the nonresponse so that he will have an opportunity to obtain and submit the records himself, in keeping with his responsibility to submit evidence in support of his claim. 38 C.F.R. § 3.159 (2012). 3. The AMC/RO should request all documents pertaining to any award of benefits to the appellant from the Social Security Administration (SSA), and specifically request a copy of the decision awarding any benefits and copies of the medical records, upon which the SSA based its decision. If the request for records is not successful, the AMC/RO should inform the appellant of the nonresponse so that he will have an opportunity to obtain and submit the records himself, in keeping with his responsibility to submit evidence in support of his claim. 38 C.F.R. § 3.159 (2012). 4. Only after all of the service member's medical records and SSA records have been obtained and included in the claims folder, the RO/AMC should arrange for the appellant to be examined by a VA doctor in order to determine whether the appellant now suffers from either a right or left knee disability. The claims folder and a copy of this remand are to be made available to the examiner to review prior to the review. The examiner should be requested to review the claims folder and state that this has been accomplished in the examination report. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is asked to express an opinion as to whether the appellant now suffers from one of the claimed disabilities (right knee disability or left knee disability) and if he does, the examiner should also opine as to whether the found disability is at least as likely as not (a probability of 50 percent or greater) related or secondary to the appellant's military service or to a service-connected disability. With respect to the left knee disability, the examiner should specifically discuss the appellant's assertions that he suffered from a left knee condition in service and that he sought treatment including surgery after service for a left knee disability. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination report. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination. For example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific service-connected disability can possibly cause the claimed condition, or the actual cause of the disability cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). As stated, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Again, in the doctor's report, the examiner must specifically discuss the appellant's contentions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, if the examiner concludes that the appellant's claimed knee disabilities are not service-related, the examiner must explain in detail the reasoning behind this determination. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. Finally, it is requested that the results be typed and included in the claims folder for review. 5. Only after all of the service member's medical records and SSA records have been obtained and included in the claims folder, the RO/AMC should arrange for the appellant to be examined by a VA doctor in order to determine whether the appellant now suffers from coronary artery disease and/or hypertension. The claims folder and a copy of this remand are to be made available to the examiner to review prior to the review. The examiner should be requested to review the claims folder and state that this has been accomplished in the examination report. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is asked to express an opinion as to whether the appellant now suffers from coronary artery disease and/or hypertension and if he does, the examiner should also opine as to whether the found disability is at least as likely as not (a probability of 50 percent or greater) related or secondary to the appellant's military service or to a service-connected disability. The examiner should also provide an opinion as to whether, as claimed by the appellant, that any found cardiac disorder is secondary to or aggravated by a psychiatric disorder. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination report. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination. For example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific service-connected disability can possibly cause the claimed condition, or the actual cause of the disability cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). As stated, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Again, in the doctor's report, the examiner must specifically discuss the appellant's contentions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, if the examiner concludes that the appellant's claimed coronary artery disease and/or hypertension are/is not service-related, the examiner must explain in detail the reasoning behind this determination. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. Finally, it is requested that the results be typed and included in the claims folder for review. 6. Only after all of the service member's medical records and SSA records have been obtained and included in the claims folder, the RO/AMC should arrange for the appellant to be examined by a VA doctor in order to determine whether the appellant now suffers from an acquired psychiatric disorder to include PTSD or a mood disorder. The claims folder and a copy of this remand are to be made available to the examiner to review prior to the review. The examiner should be requested to review the claims folder and state that this has been accomplished in the examination report. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is asked to express an opinion as to whether the appellant now suffers from a psychiatric disorder and if he does, the examiner should also opine as to whether the found disability is at least as likely as not (a probability of 50 percent or greater) related or secondary to the appellant's military service or to a service-connected disability. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination report. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination. For example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific service-connected disability can possibly cause the claimed condition, or the actual cause of the disability cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). As stated, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Again, in the doctor's report, the examiner must specifically discuss the appellant's contentions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, if the examiner concludes that the appellant's claimed psychiatric disorder is not service-related, the examiner must explain in detail the reasoning behind this determination. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. Finally, it is requested that the results be typed and included in the claims folder for review. 7. Only after all of the service member's medical records and SSA records have been obtained and included in the claims folder, the RO/AMC should arrange for the appellant to be examined by a VA doctor in order to determine whether the appellant now suffers from chronic obstructive pulmonary disease (COPD). The claims folder and a copy of this remand are to be made available to the examiner to review prior to the review. The examiner should be requested to review the claims folder and state that this has been accomplished in the examination report. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is asked to express an opinion as to whether the appellant now suffers from COPD and if he does, the examiner should also opine as to whether the found disability is at least as likely as not (a probability of 50 percent or greater) related or secondary to the appellant's military service or to a service-connected disability. The examiner should further offer an opinion as to whether any found pulmonary disorder is secondary to or was caused by asbestos exposure, chemical dioxin exposure, or other chemical aerosol exposure. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination report. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination. For example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific service-connected disability can possibly cause the claimed condition, or the actual cause of the disability cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). As stated, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Again, in the doctor's report, the examiner must specifically discuss the appellant's contentions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, if the examiner concludes that the appellant's claimed COPD is not service-related, the examiner must explain in detail the reasoning behind this determination. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. Finally, it is requested that the results be typed and included in the claims folder for review. 8. Only after all of the service member's medical records and SSA records have been obtained and included in the claims folder, the RO/AMC should arrange for the appellant to be examined by a VA doctor in order to determine whether the appellant now suffers from irritable bowel syndrome (IBS). The claims folder and a copy of this remand are to be made available to the examiner to review prior to the review. The examiner should be requested to review the claims folder and state that this has been accomplished in the examination report. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is asked to express an opinion as to whether the appellant now suffers from IBS, and if he does, the examiner should also opine as to whether the found disability is at least as likely as not (a probability of 50 percent or greater) related or secondary to the appellant's military service or to a service-connected disability. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination report. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination. For example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific service-connected disability can possibly cause the claimed condition, or the actual cause of the disability cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). As stated, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Again, in the doctor's report, the examiner must specifically discuss the appellant's contentions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, if the examiner concludes that the appellant's claimed IBS is not service-related, the examiner must explain in detail the reasoning behind this determination. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. Finally, it is requested that the results be typed and included in the claims folder for review. 9. Only after all of the service member's medical records and SSA records have been obtained and included in the claims folder, the RO/AMC should arrange for the appellant to be examined by a VA doctor in order to determine whether the appellant now suffers from Sjoren's syndrome. The claims folder and a copy of this remand are to be made available to the examiner to review prior to the review. The examiner should be requested to review the claims folder and state that this has been accomplished in the examination report. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is asked to express an opinion as to whether the appellant now suffers from Sjoren's syndrome, and if he does, the examiner should also opine as to whether the found disability is at least as likely as not (a probability of 50 percent or greater) related or secondary to the appellant's military service or to a service-connected disability. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination report. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination. For example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific service-connected disability can possibly cause the claimed condition, or the actual cause of the disability cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). As stated, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Again, in the doctor's report, the examiner must specifically discuss the appellant's contentions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, if the examiner concludes that the appellant's claimed Sjoren's syndrome is not service-related, the examiner must explain in detail the reasoning behind this determination. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. Finally, it is requested that the results be typed and included in the claims folder for review. 10. Following completion of the foregoing, the RO/AMC must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the requested doctors' opinions. If the reports do not include fully detailed responses to the questions/comments asked therefor, the reports must be returned for corrective action. 38 C.F.R. § 4.2 (2012) and Stegall v. West, 11 Vet. App. 268 (1998). 11. Thereafter, the RO/AMC should readjudicate the claims. If the benefits sought on appeal remain denied, the appellant and the appellant's accredited representative should be provided a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claims for benefits, to include a summary of the evidence and applicable law and regulations considered pertinent to the issues currently on appeal. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. The purpose of the examinations requested in this remand is to obtain information or evidence (or both) which may be dispositive of the appeal. Therefore, the appellant is hereby placed on notice that pursuant to 38 C.F.R. § 3.655 (2012) failure to cooperate by attending the requested VA examinations may result in an adverse determination. See Connolly v. Derwinski, 1 Vet. App. 566, 569 (1991). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ C. TRUEBA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs