Citation Nr: 1237991 Decision Date: 11/06/12 Archive Date: 11/16/12 DOCKET NO. 07-12 531 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from June 2003 to May 2005. She also had service with the U.S. Army National Guard for more than 20 years; presumably this includes periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). Subsequent to the Board's December 2010 remand, the Appeals Management Center (AMC) obtained the Veteran's service personnel file, but was not able to verify any specific period of ACDUTRA as requested. It appears from a review of her Army National Guard annual statement of retirement points that she did have periods of ACDUTRA and such would be consistent with her type of service in the National Guard over many years. For the reasons cited below in the discussion of her claim, the Board believes she will suffer no prejudice in the adjudication of this issue. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Subsequently, the claims file was returned to the jurisdiction of the RO in Atlanta, Georgia. In January 2010 and December 2010, the Board remanded this matter for further development. In October 2009, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is of record. The following determination is based on review of the Veteran's claims file in addition to her Virtual VA "eFolder." While the Veteran has not submitted a waiver of initial RO consideration for some of the most recent treatment records found in her eFolder dated from April 2011 to February 2012, the Board finds that such records are either not pertinent to the claim currently on appeal or, where potentially pertinent, are duplicative of other evidence in the record. Therefore, the Veteran is not prejudiced by the Board's initial consideration of this evidence. 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. Clear and unmistakable evidence demonstrates that the Veteran's hypertension existed prior to her periods of active service. 2. Clear and unmistakable evidence demonstrates that the Veteran's hypertension did not permanently increase in severity during or as a result of her active service. CONCLUSIONS OF LAW 1. The Veteran's hypertension clearly and unmistakably existed prior to her periods of active service and was not aggravated by active service, and the presumption of soundness is rebutted. 38 U.S.C.A. §§ 1110, 1111, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.304, 3.306 (2012). 2. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1111, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA Before addressing the merits of the issue on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183, (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been satisfied. The Veteran was notified via letters dated in July 2005, September 2005, and January 2010 of the criteria for establishing service connection for hypertension, the evidence required in this regard, and her and VA's respective duties for obtaining evidence. She also was notified of how VA determines disability ratings and effective dates if service connection is awarded in the January 2010 letter. The Board notes that the Veteran did not receive complete VCAA notice before the initial adjudication by the AOJ of her hypertension disability claim in December 2005. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Such was done in this case. After all notices were sent to the Veteran, her claim currently on appeal was readjudicated in a February 2012 SSOC. As for the duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. The Veteran's National Guard and service personnel and treatment records as well as post-service VA treatment records have been obtained and considered. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Neither the Veteran nor her representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran was provided an opportunity to set forth her contentions regarding her hypertension claim during her Board hearing in October 2009 before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (CAVC) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the October 2009 hearing the undersigned identified the issue on appeal as service connection for hypertension. At the hearing, information was solicited regarding the nature and etiology of her hypertension disability. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence other than post-service VA treatment records that might be available that had not been submitted. After the hearing, the record was left open for 30 days to permit submission of these VA medical records. Next, a specific VA examination and opinion was obtained in March 2010 regarding the Veteran's claim for hypertension. 38 C.F.R. § 3.159(c) (4). 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 examination and opinion obtained in this case is more than adequate, as it was predicated on a reading of the Veteran's claims file and an interview of the Veteran. The VA examiner considered all of the pertinent evidence of record, to include her service treatment records, personal statements, and history and provided a detailed rationale for the opinion stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding this issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Additionally, the Board finds there has been substantial compliance with its January 2010 and December 2010 remand directives. The Board notes that the CAVC has recently noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). The record indicates that the Appeals Management Center (AMC) was directed in the remands to obtain all of the Veteran's service personnel records to determine a breakdown of any periods of active duty or ACDUTRA, request the Veteran provide the identities of all providers, schedule a VA examination and medical opinion, and provide proper VCAA notice. The record further indicates that the RO/AMC attempted all these tasks, although it was not able to verify any period of ACDUTRA before June 2003 and the Veteran did not provide the identity of any private health practitioner treating her hypertension. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remands. See Stegall, 11 Vet. App. 268 (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). The Board concludes that all available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, the Board finds that VA has complied with the duty-to-assist requirements. 38 U.S.C.A. § 5103A. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303. Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110. ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserves. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full-time duty performed by a member of the Reserves or the National Guard of any State. 38 C.F.R. § 3.6(d). VA regulations provide that where a veteran served 90 days or more of continuous, active military service during a period of war or after January 1, 1947, and certain chronic diseases, including hypertension, become manifest to a degree of 10 percent within one year from date of termination of service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Presumptive periods do not apply to periods of ACDUTRA and INACDUTRA. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Generally, in order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) 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 disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The Federal Circuit has held that a veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. See 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306. "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence"). It is an "onerous" evidentiary standard, requiring that the pre-existence of a condition and the no-aggravation result be "undebatable." See Cotant v. West, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. See VAOPGCPREC 3-2002; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. §§ 3.304, 3.306(b). A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of a disability. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). A finding of aggravation is not appropriate in cases where the evidence specifically shows that the increase is due to the natural progress of the disease. Furthermore, temporary or intermittent flare-ups of a pre-existing disease during service are not sufficient to be considered aggravation of the disease unless the underlying condition, as contrasted to symptoms, worsens. See Jensen v. Brown, 4 Vet. App. 304, 306-7 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). 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). The Board must assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. Factual Background The Veteran claims that her hypertension is related to service, specifically, by way of aggravation of pre-existing hypertension. During her Board hearing, the Veteran testified that she was diagnosed with hypertension in 2002, prior to being called to active duty, that she was monitored and took medication, and that her hypertension was under control prior to her activation for service. (See transcript at pp. 8-9.) Service personnel records indicate that she enlisted in the Army National Guard in December 1977. Subsequent to the Board's last remand, the RO indicated that it was not able to delineate any specific period of ACDUTRA before her two periods of consecutive active duty from June 2003 to May 2004 and from May 2004 to May 2005. The Board observes that for VA purposes, hypertension means that the diastolic pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic pressure is predominantly 160mm or greater with a diastolic pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). A review of service treatment records before the Veteran was called to active duty in June 2003 suggests she may have been diagnosed with hypertension even earlier than 2002. An August 1991 risk appraisal profile noted that the Veteran's blood pressure (118/90) was mildly high. A Georgia Army National Guard examination dated in April 1999 showed a blood pressure reading of 176/72 and a history of hypertension for which she was taking medication. On a contemporaneous report of medical history she also checked the "yes" box to a question whether she had high blood pressure. A March 2002 National Guard treatment record noted that the Veteran was taking medication for hypertension. Army health clinic records dated in November 2002 for a National Guard retention examination reveal the Veteran had a history of hypertension for which she took medication. Blood pressure readings noted that month were 126/81, 138/89, 135/89, and 140/84. On a form completed in April 2003 the Veteran noted that she was taking medication for hypertension, which was under control by medication. In June 2003, when the Veteran was called up for active duty, service treatment records noted her hypertension was controlled by medication and that a five-day blood pressure check, measured on both arms while she stood and sat, was within normal limits. Subsequent service treatment records during her period of active duty show blood pressure readings of: 134/56 (in September 2003); 148/88 (in October 2003); 122/62 (in November 2003); 136/75 (in March 2004); 133/78 (in April 2004); 121/75 and 152/80 (in May 2004); 143/84 (in June 2004); 161/86, 121/78, and 141/82 (in July 2004); 137/77 (in August 2004); 122/80 and 146/84 (in September 2004); 132/87 (in October 2004); 145/82 (in February 2005); 140/84 and 156/85 (in March 2005); and 109/74 (in April 2005). The September 2003 service treatment record specifically noted that her hypertension was controlled. On an October 2004 report of medical history an examiner noted that the Veteran's blood pressure was controlled by medication. The Veteran's April 2004 and May 2005 post-deployment health assessments or discharge examinations failed to note any complaints or treatments for hypertension. Post-discharge VA medical records found in the claims file and in the Veteran's eFolder on the Virtual VA system show continuing treatment for hypertension. During her Board hearing in October 2009, the Veteran testified that she was diagnosed with hypertension in 2002 and took medications and was being monitored before she entered active duty. Once on active duty, the Veteran said that her blood pressure readings became elevated and that stressful situations in service at Fort Meade, Maryland, made it go up. (See transcript at pp. 8-9.) The Veteran underwent a VA examination in March 2010. The Veteran told the examiner that her hypertension predated her enlistment in the service and that she was diagnosed in the mid-1990s and started medications at that time. When the examiner and Veteran used the phrase "enlistment" in service context strongly suggests they apparently referred to her call up for active duty in June 2003 and not her enlistment in the National Guard back in 1977. The Veteran recalled good control of her hypertension with her medicines until active duty. Then, she told the examiner, her blood pressure control changed. She had to be at work at 2 a.m. and felt increased stress with these hours. She said that her anxiety and stress were elevated with patrolling dark wooded areas. The VA examiner noted that the Veteran's blood pressure was controlled currently in the range of 130/70s, that she was taking HCTZ and Valsartan daily, and that her father and sister also had hypertension. On examination, blood pressure readings on both arms sitting and standing were as follows: 124/78, 130/88, and 126/76. The VA examiner opined that it was at least as likely as not that the Veteran has essential hypertension and was diagnosed with such in the 1990s prior to her periods of active duty, which began in 2003. Therefore, the examiner found that it was at least as likely as not that the Veteran's hypertension pre-existed her entry into active duty in June 2003. The examiner also opined that it was less likely than not that such hypertension was aggravated or permanently worsened by active service. The examiner explained that the Veteran's hypertension was currently well-controlled and not disabling and similar to reported numbers prior to active duty. The two medications the Veteran was taking for her hypertension were as likely as not due to the natural progression of her hypertension over time. The VA examiner also noted that there was no evidence of organ damage. Analysis Based on the evidence of record, the Board finds that service connection is not warranted for the Veteran's hypertension. As noted above, Wagner held that when no pre-existing condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both pre-existing and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the" pre-existing condition. 38 U.S.C. § 1153. If this burden is met, then the Veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under 38 U.S.C.A. § 1111, the Veteran's claim is one for direct service connection. See Wagner, 370 F.3d at 1094-96; 38 U.S.C.A. § 1153. In this case, there is no question that the file contains clinical evidence of a currently diagnosed hypertension disorder. The pertinent inquiry in this case involves whether or not the Veteran's currently diagnosed hypertension was incurred in or aggravated by her two periods of active service from June 2003 to May 2005 or during some verified period of ACDUTRA. As noted above, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA, but only from an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110. Hypertension, of course, is a disease and not an injury so periods of INACDUTRA are irrelevant to this case. As noted in the Introduction, VA has not been able to verify any specific dates of her presumed periods of ACDUTRA; but the Veteran's periods of active duty service are known. There is no suggestion from the Veteran or her representative that onset of her hypertension during a period of either active duty service or during a period of ACDUTRA. The Board has reviewed a quite extensive amount of medical records covering many years and has found no evidence that her hypertension was incurred during a period of ACDUTRA. Her sole contention is that her pre-existing hypertension was aggravated during her periods of active duty service. Therefore, the Board will examine whether there is clear and unmistakable evidence that the Veteran's hypertension pre-existed her first period of active duty beginning in June 2003 and was aggravated thereafter on active duty. Available National Guard and service treatment records provide no indication that any hypertension disorder was noted upon entry into active duty service in June 2003. However, even so, the Board finds that the file contains evidence which clearly and unmistakably establishes that a hypertension disorder existed prior to the Veteran's entry into active service in June 2003. As noted above, National Guard treatment records going back to August 1991 showed mildly high blood pressure and April 1999 and November 2002 National Guard examinations showed a history of hypertension for which the Veteran was taking medication. In addition, the Veteran noted on an April 2003 form that she was taking medication for hypertension which was under control. The March 2010 VA examiner also opined, although she did not use the clear and unmistakable standard, that the Veteran's hypertension pre-existed her enlistment into active service based on a review of the evidence in the claims file. There is no clinical evidence on file to the contrary. The Board notes that in light of such clear and unmistakable evidence, it must reach the conclusion that the Veteran's hypertension disorder clearly and unmistakably existed prior to service. The Board further finds clear and unmistakable evidence demonstrating that the Veteran's pre-existing hypertension did not increase in severity during her verified periods of active service. Available service treatment records from September 2003 to April 2005 detail a history of blood pressure readings showing, almost without exception, that the Veteran's blood pressure did not reach the level considered evidence of hypertension in VA regulations. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). In addition, records dated in October 2003 and October 2004 noted that the Veteran's hypertension was controlled by medication and her April 2004 and May 2005 health assessments failed to note any complaints or treatments related to hypertension. Therefore, except for one reading of 161/86 in July 2004, there is no indication of a possible increase or worsening of hypertension during service. The Board notes that her blood pressure registered 121/78 and 141/82 on two other occasions in July 2004. Of substantial probative value in this regard is the medical conclusion of the March 2010 VA examiner who opined, although not using the correct clear and unmistakable standard, that it was less likely than not that the Veteran's hypertension was aggravated or permanently worsened by active service. The VA examiner explained that the Veteran's hypertension was currently well-controlled and not disabling, her blood pressure readings were similar to reported numbers prior to active duty, and the two medications she took for hypertension were as likely as not due to the natural progression of her hypertension over time. The VA examiner also noted that there was no evidence of organ damage. See Stadin v. Brown, 8 Vet. App. 280, 285 (1995) (holding that a medical conclusion that a Veteran's pre-existing condition has not progressed at a rate greater than is usual for such disorders was sufficient to rebut the presumption of aggravation and establish that the in-service worsening of the veteran's disorder was due to the natural progress of the disease). It is clear to the Board that the VA examiner was attempting to articulate that the Veteran's pre-existing hypertension clearly and unmistakably was not permanently increased during her active duty service. This conclusion is based on the context, rationale and observations found in the March 2010 VA examination and medical opinion. There is no medical evidence in the claims file to indicate that the Veteran's service experience had brought about her hypertension. In other words, according to the VA examiner, the evidence of record supports a finding that the Veteran's hypertension disorder existed prior to the Veteran's first period of active service in June 2003 and was not permanently aggravated beyond the natural progression of the condition by active duty service over the next two years. In this case, the Board finds that the context and rationale of the March 2010 VA medical examination and opinion, along with the service treatment records of blood pressure readings, are sufficient to rebut any suggestion of aggravation during service and establish that the Veteran's symptoms of hypertension, during service and since, were due to the natural progress of her disorder. The fact that the Veteran complained that her stress had increased while on active duty does not change this conclusion, particularly in view of the medical evidence of record taking this into account. In light of the evidence of record, the Board finds that the Veteran's hypertension was shown by clear and unmistakable evidence to have existed prior to active duty service with no increase in severity during or as a result of her active duty service. Accordingly, the Board finds that the presumption of soundness was rebutted in this case. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.303. In making the above determinations, the Board has carefully considered the Veteran's lay assertions. She generally contended there was an increase in the severity of her hypertension due to active duty service because her blood pressure readings had increased and she was placed in more stressful situations, such as patrolling in the dark. Although the Veteran's lay assertions are generally considered competent to assess pre-service and in-service symptomatology, she has not been shown to possess the requisite medical training or credentials needed to render an opinion regarding the diagnosis or degree of aggravation of hypertension. Therefore, her lay opinion in this regard does not constitute competent medical evidence in support of her claim and lacks probative value with regard to the issue on appeal. See Jandreau, 492 F.3d at 1376-77. While the Veteran is certainly competent to state that she had trouble with her blood pressure in service and assume her credible, in view of the medical evidence which takes into account the Veteran's account of her symptoms, the probative value of the medical evidence outweighs the Veteran's contentions. In conclusion, the Board finds that hypertension clearly and unmistakably pre-existed the Veteran's periods of active service and was not aggravated therein. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The preponderance of the evidence in this case is against the Veteran's claim and the claim, therefore, is denied. ORDER Service connection for hypertension is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs