Citation Nr: 1301219 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 06-07 035A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for the cause of the Veteran's death. 2. Entitlement to service connection for pulmonary fibrosis, for accrued purposes only. 3. Entitlement to service connection for anemia, to include a blood disorder, for accrued purposes only. 4. Entitlement to service connection for a gastrointestinal disorder, for accrued purposes only. 5. Entitlement to service-connected burial benefits. WITNESSES AT HEARING ON APPEAL Appellant, Appellant's niece ATTORNEY FOR THE BOARD K. Millikan, Counsel INTRODUCTION The Veteran served on active military duty from February 1954 to July 1981, with Vietnam service from April 1969 to March 1970. The Veteran died in March 2005. The Appellant is the surviving spouse of the Veteran. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2005 rating decision by the Muskogee, Oklahoma, Regional Office (RO) of the Department of Veterans Affairs (VA) and August 2007 and June 2009 Board remands. In October 2006, the Appellant and her niece testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims file. FINDINGS OF FACT 1. The Veteran's death certificate reflects that the immediate cause of death was pulmonary embolus due to or a consequence of pulmonary fibrosis. 2. At the time of his death, the Veteran was service-connected for hearing loss, tinnitus, and otitis media. 3. Pulmonary fibrosis, a gastrointestinal disorder, and anemia are not shown to be related to service, to include Agent Orange exposure CONCLUSIONS OF LAW 1. A disability incurred in or aggravated by service, or a disability that is otherwise related to service, did not cause or contribute substantially or materially to the cause of the Veteran's death. 38 U.S.C.A. §§ 1110, 1112, 1113, 1310, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.312 (2012). 2. Pulmonary fibrosis, anemia, and a gastrointestinal disorder were not incurred in or aggravated by active military service, nor may they be presumed to have been so incurred, to include as due to Agent Orange exposure. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. The criteria for service-connected burial benefits are not met. 38 U.S.C.A. §§ 2302, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.1600 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminarily, the Board notes at the time of the Veteran's death, he had three service connection claims pending before the RO. As a matter of law, Veterans' claims do not survive their deaths. Zevalkink v. Brown, 102 F.3d 1236, 1243-44 (Fed. Cir. 1996); cert. denied, 117 S. Ct. 2478 (1997); Smith v. Brown, 10 Vet. App. 330, 333-34 (1997); Landicho v. Brown, 7 Vet. App. 42, 47 (1994). As authorized by law, however, the Appellant has filed a claim for accrued benefits deriving from the Veteran's pending claims. See Jones v. West, 136 F.3d 1296, 1300 (Fed. Cir. 1998); cert. denied, 525 U.S. 834 (1998) (surviving spouse's entitlement to a Veteran's accrued benefits is a derivative claim, and is viable only if the Veteran had a claim pending at death). The Board also notes that the Appellant has exclusively claimed, and the RO exclusively adjudicated, service-connected burial benefits, as opposed to non-service-connected burial benefits. Accordingly, the issues are as listed above and addressed below. Veterans Claims Assistance Act of 2000 (VCAA) Under the VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and 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. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the context of a claim of service connection for cause of death, VCAA notice must include (1) a statement of the conditions, if any, for which a Veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, VA's duty to notify has been satisfied. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). May 2005, August 2007, July 2009, October 2009, and March 2010 letters were sent to the Appellant. Those letters provided the required notice for accrued benefits claims, service connection claims, and the Appellant's cause of death claims. Although not all of the letters were not sent prior to initial adjudication of the claims, there is no prejudice to the Appellant in proceeding to adjudication of this claim. This is because the letters were followed by a readjudication of the claims in a December 2010 supplemental statement of the case. Prickett, 20 Vet. App. at 376. Accordingly, VA's duty to notify has either has been satisfied or any deficiency has caused no prejudice to the Appellant. VA's duty to assist the Appellant has also been satisfied. 38 U.S.C.A. § 5103A(a)(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records (STRs), VA medical records, and identified private medical records have been obtained. Regarding the accrued benefits claims, because these claims are based on the records of file as the time of the Veteran's death, VA did not obtain opinions regarding these claims. See 38 U.S.C.A. § 5121(a); 38 C.F.R. § 3.1000(a); Zevalkink v. Brown, 102 F.3d 1236, 1241-42 (Fed. Cir. 1996). Regarding the cause of death claim, VA obtained a November 2011 opinion. See 38 U.S.C. § 5103A(a) (West 2002); Delarosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008) (noting that Section 5103A(a), and not (d), applies to DIC claims, and requires that VA need only obtain a medical opinion when such opinion is "necessary to substantiate the claimant's claim for a benefit"). The opinion was adequate because it was based upon a review of the relevant evidence of record and was supported by a thorough explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that a central issue in the persuasiveness of a medical opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Additionally, the Appellant provided testimony at an October 2006 Board hearing. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. Regarding the claim for service-connected burial benefits, as is further discussed below, the law, and not the facts, is dispositive of this issue. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The VCAA is not applicable where resolution of the claim is as a matter of law. See Manning v. Principi, 16 Vet. App. 534, 542 (2002) (holding that the VCAA has no effect on an appeal limited to matter of law); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (noting that the VCAA is not applicable where law is dispositive). Accordingly, any failure in VA's duty to notify or assist regarding this claim is not prejudicial. Compliance with prior Board remands A Court or Board remand confers upon the Appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Substantial compliance, rather than strict compliance, is required. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). In the context of an examination, there is no Stegall violation when an examiner makes the ultimate determination required by the Board's remand, because such determination constitutes substantial compliance. Dyment v. West, 13 Vet. App. 141, 146-47 (1999) The Board finds that there has been substantial compliance with the prior August 2007 Board remand. That remand requested the following development: 1) a letter providing specific notice; 2) contact various private medical providers for records; 3) obtain VA medical records from Lawton/Fort Sill and Oklahoma City for specific time frames; 4) contact Reynolds Army Hospital for records; and 5) if no records were available from Reynolds Army Hospital, to contact the National Personnel Records Center (NPRC). An August 2007 letter provided the required notice to the Appellant. The Oklahoma City, Oklahoma VA Medical Center (VAMC) notified VA that all records had been transferred to the Lawton, Oklahoma VAMC. In September 2007, all records from the Lawton VAMC were provided to VA. In August 2007, VA contacted Reynolds Army Hospital and the NPRC for records. In August 2008, additional medical records from the Oklahoma City VAMC were provided to VA. That same month, Reynolds Army Hospital responded that there were no records at that facility for the 1980s, except for an attached x-ray history and lab which were dated in 2000 and 2001. The NPRC provided a negative response for any records from Reynolds Army Hospital. There was not substantial compliance with the request to contact the private medical providers and obtain records; this was the basis for a subsequent June 2009 Board remand. Accordingly, the Board finds that there has been substantial compliance with this remand. The Board also finds that there has been substantial compliance with the June 2009 remand. That remand requested that VA send the Appellant specific VCAA notice. Letters that met the requirements were sent in July and October 2009. The remand also requested that VA obtain releases from the Appellant for various medical providers. A request for such releases was included in the July 2009 VCAA letter. The Appellant returned releases for some, but not all, of the providers. An October 2009 letter notified the Appellant that she had not provided release forms for all of the requested providers. She did not provide the releases. For the providers for which the Appellant provided release forms, the medical records were obtained. For the other private medical providers, the Board notes that "the duty to assist is not always a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). If an Appellant wishes assistance from VA, she "cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood, 1 Vet. App. at 193. Thus, the Board finds that there has been substantial compliance with the prior remand and that this appeal is ready for adjudication. Service connection for the cause of the Veteran's death The Appellant alleges that the Veteran's cause of death, pulmonary embolus, caused by pulmonary fibrosis, is caused by service, to include as due to Agent Orange exposure. At the October 2006 hearing she asserted that the Veteran began having lung problems after he went to Germany in either 1973 or 1980. The Appellant does not assert that the Veteran's service-connected conditions, including hearing loss, tinnitus, and otitis media, are the cause of the Veteran's death. She also does not allege that his gastrointestinal conditions or anemia caused the Veteran's death. The death of a Veteran will be considered as having been due to a service-connected disability where the evidence establishes that such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). A principal cause of death is one which, singularly or jointly with some other condition, was the immediate or underlying cause of death, or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributes substantially or materially to death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). Service-connected disabilities or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there was resulting debilitating effects and general impairment of health to the extent that would render the person less capable of resisting the effects of either disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of co-existing conditions, but, even in such cases, there is for consideration whether there may be reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. 38 C.F.R. § 3.312(c)(4). Service connection for the cause of a Veteran's death may be demonstrated by showing that the Veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may 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 there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 496 (1997). A layperson is competent to identify such disorders as varicose veins, tinnitus, and flat feet. Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). A layperson is not competent to identify medical conditions that require scientific, technical, or other specialized knowledge, such as in identifying bronchial asthma. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay statements do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Lay testimony, however, is competent to establish a diagnosis where the layperson is competent to identify the medical condition, is reporting a contemporaneous medical diagnosis, or describes symptoms that support a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). If a Veteran was exposed to Agent Orange during active service, presumptive service connection is warranted for certain specified diseases. 38 C.F.R. §§ 3.307, 3.309. A Veteran is presumed exposed to Agent Orange if he or she had active military, naval, or air service, in the Republic of Vietnam from January 9, 1962 through May 7, 1975, "unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The Veteran has the required Vietnam service; Agent Orange exposure is presumed. If a Veteran was exposed to Agent Orange during active service, service connection is presumed for the following disorders: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes; Hodgkin's disease ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), but excluding hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease; all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. §§ 3.307(a)(6), 3.309(e). A presumption of service connection based on Agent Orange exposure in the Republic of Vietnam during the Vietnam era is not warranted for: hypertension; cancers of the oral cavity (including lips and tongue), pharynx (including tonsils), or nasal cavity (including ears and sinuses); cancers of the pleura, mediastinum, and other unspecified sites within the respiratory system and intrathoracic organs; esophageal cancer; stomach cancer; colorectal cancer (including small intestine and anus); hepatobiliary cancers (liver, gallbladder and bile ducts); pancreatic cancer; bone and joint cancer; melanoma; non-melanoma skin cancer (basal cell and squamous cell); breast cancer; cancers of reproductive organs (cervix, uterus, ovary, testes, and penis; excluding prostate); urinary bladder cancer; renal cancer (kidney and renal pelvis); cancers of brain and nervous system (including eye); endocrine cancers (thyroid, thymus, and other endocrine organs); leukemia (other than all chronic B-cell leukemias including chronic lymphocytic leukemia and hairy cell leukemia); cancers at other and unspecified sites; neurobehavioral disorders (cognitive and neuropsychiatric); movement disorders (including amyotrophic lateral sclerosis, but excluding Parkinson's disease); chronic peripheral nervous system disorders; respiratory disorders (wheeze or asthma, chronic obstructive pulmonary disorder, and farmer's lung); gastrointestinal, metabolic, and digestive disorders (changes in liver enzymes, lipid abnormalities, and ulcers); immune system disorders (immune suppression, allergy, and autoimmunity); circulatory disorders (other than ischemic heart disease); endometriosis; effects on thyroid homeostasis; certain reproductive effects, i.e., infertility, spontaneous abortion, neonatal or infant death and stillbirth in offspring of exposed people, low birth weight in offspring of exposed people, birth defects (other than spina bifida) in offspring of exposed people, childhood cancer (including acute myelogenous leukemia) in offspring of exposed people; and any other condition for which VA has not specifically determined a presumption of service connection is warranted. 75 Fed. Reg. 81332 (Dec. 27, 2010); 75 Fed. Reg. 32540 (June 8, 2010); 72 Fed. Reg. 32395 (June 12, 2007); 68 Fed. Reg. 27630-27641 (May 20, 2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (November 2, 1999); 59 Fed. Reg. 341 (Jan. 4, 1994); 61 Fed. Reg. 41442 (Aug. 8, 1996). The Veteran's cause of death was listed on the death certificate as pulmonary embolus due to or as a consequence of pulmonary fibrosis. The Veteran's STRs from 1954 to 1981 are silent for a diagnosis of pulmonary fibrosis or embolus. Various chest x-rays noted no significant abnormality. The Veteran intermittently reported whooping cough and pneumonia on reports of medical history. Multiple reports of medical examination noted normal lungs and chest, although a 1971 report indicated a history of pneumonia in 1954. VA and private medical records in the 1980s and early 1990s indicate treatment for peripheral vascular disease, treatment for ear, nose, and throat conditions, including hearing loss, and treatment for heart conditions. Private medical records beginning in 1999 indicate diagnoses of pulmonary fibrosis. A 1999 chest x-ray noted fibrotic changes. Three private medical opinions are associated with the claims file. In a September 2004 submission, Dr. TL stated that the Veteran had pulmonary fibrosis and chronic anemia and that it was more likely than not that the end stage lung problem dates back to active duty. In an August 2005 submission, Dr. TL stated that it was more likely than not that pulmonary fibrosis was related to military service. In an October 2006 submission, Dr. TL provided an opinion based upon a review of the medical records and his treatment of the Veteran. Dr. TL opined that the medical conditions relating to the Veteran's lungs were a result of things connected with his military service, including Agent Orange and other pesticide exposures, even though the majority of the signs and symptoms did not appear until after service discharge. Dr. TL noted that the conditions often take years to appear. At the October 2006 Board hearing, the Appellant and her niece testified that the Veteran had lung problems and pneumonia in either 1973 or 1980-1981. They testified that the Veteran went to Reynolds Army Hospital around that time for lung problems and a heart attack and that he was hospitalized for approximately three weeks. An October 2011 VA medical opinion was obtained from a pulmonologist. The examiner reviewed the claims file, including the relevant medical records. The examiner opined that it was less likely than not that the pulmonary embolus or pulmonary fibrosis had onset during service or were causally related to service, including as due to Agent Orange exposure. The examiner also opined that it was less likely than not that the Veteran manifested signs and symptoms of the pulmonary fibrosis continuously since service discharge. The examiner conducted a thorough review and analysis of the medical evidence, beginning with the notation of pneumonia in 1954 with no sequelae, and a history of whooping cough. STRs contained normal chest x-rays in 1968 and 1981. The examiner also noted that by the 1990s, records showed tobacco usage. In 1999, the Veteran was admitted to the hospital for pneumonia. A chest x-ray noted fibrotic changes. Over the next few years, x-rays intermittently note pulmonary fibrosis. Pulmonary function testing in 2002 had results more consistent with a chronic obstructive pulmonary disorder diagnosis than pulmonary fibrosis. From 2003 to 2005, the Veteran was admitted to the hospital several times for pneumonia, acute pulmonary insufficiency, pulmonary fibrosis, and anemia requiring blood transfusions. On March [redacted], 2005, the Veteran presented with severe acute dyspnea and a few hours later died of multiple pulmonary emboli. A bone marrow biopsy in March 2005 indicate hypercellularity and erythroid hyperplasia but was negative for atypical infiltrates thus ruling out myeloma, leukemia, and lymphoma. The examiner explained that pulmonary fibrosis was not detected until 1999, almost 20 years after service discharge, which was too long of a time for occupational fibrosis to be caused by exposures in Vietnam. The examiner also noted that there were no significant, recurrent pulmonary issues until 2003, and that there were many known medical complications from Agent Orange exposure, but that the conditions were not among those complications. The Board finds that the evidence of record does not support service connection for pulmonary fibrosis, and thus service connection for the cause of the Veteran's death is not warranted. See 38 C.F.R. § 3.312. It is undisputed that the cause of the Veteran's death was pulmonary embolus due to pulmonary fibrosis. But the preponderance of the evidence demonstrates that pulmonary fibrosis is not related to service, to include Agent Orange exposure. See 38 C.F.R. §§ 3.303, 3.307, 3.309. The STRs are silent for any pulmonary fibrosis. The STRs also contained normal chest x-rays, although there was a history of whooping cough and pneumonia provided by the Veteran. Additionally, pulmonary fibrosis was not noted until the late 1990s, well over ten years after service discharge. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of disorder). Furthermore, pulmonary fibrosis is not a condition for which presumptive service connection is provided for Agent Orange exposure. See 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Moreover, the probative medical evidence of record demonstrates that pulmonary fibrosis is not related to active service, was not continuously present since service, and is not due to Agent Orange exposure. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Although September 2004 and August 2005 opinions by Dr. TL provided positive nexus opinions, the Board does not find these opinions significantly probative. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board must assess the probative value of the medical evidence in the record). The opinions did not indicate that a review of the relevant medical records was conducted nor provide any supporting explanation or rationale. See Stefl, 21 Vet. App. at 125 (holding that a mere medical conclusion is insufficient to permit the Board to make an informed decision regarding the probative value of that opinion). An October 2006 opinion provided by Dr. TL upon review of medical records, was that the conditions were due to service, noting that the conditions often take years to appear. Despite a lack of notation regarding which records were reviewed, and an abbreviated supporting explanation, the Board finds this opinion at least minimally probative. See Stefl, 21 Vet. App. at 124 ("Without a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing"). The Board finds, however, that this opinion is outweighed by the 2011 VA medical opinion. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (noting that the Board may appropriately favor the opinion of one competent medical authority over another). The November 2011 VA opinion was that it was less likely than not that the pulmonary embolus and pulmonary fibrosis had onset during service, were causally related to service, including as due to Agent Orange exposure, or that signs and symptoms of the pulmonary fibrosis had been continuous since service discharge. First, the opinion was provided by a pulmnologist, an expert in the relevant medical field. Second, the examiner undertook an extensive review and recitation of the relevant evidence, including the notations of pneumonia and whooping cough during service, and normal in-service chest x-rays. Third, the examiner noted the lapse in time between service discharge and the initial diagnosis of pulmonary fibrosis and to when recurrent and significant pulmonary problems manifested in 2003. Last, the examiner noted that pulmonary fibrosis was not among the known complications from Agent Orange exposure. These factors demonstrate that the VA examiner performed an exhaustive review of the relevant information, including medical records, and provided a more thorough supporting explanation than any other opinion of record. See Nieves-Rodriguez, 22 Vet. App. at 301-04; Stefl, 21 Vet. App. at 124. Accordingly, the Board places significant weight and probative value on this opinion. Although the Appellant and her niece provided competent testimony that the Veteran experienced respiratory problems during service and thereafter, the Board does not find this testimony competent for the purpose of demonstrating signs and symptoms of a particular lung disorder, here, pulmonary fibrosis. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (noting that lay evidence may not be categorically dismissed as not competent regarding questions of medical etiology). Although the Appellant and her niece are competent to testify as the Veteran's respiratory symptoms over a period of time, any testimony regarding the presence and etiology of pulmonary fibrosis requires more than lay knowledge because diagnosing and distinguishing between various lung disorders requires expert medical knowledge. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) ("When the question involved does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge, then the opinions of witnesses skilled in that particular science, art, or trade to which the question relates are admissible in evidence.") (quoting Frye v. United States, 293 F. 1013, 1014 (1923)). Medical expert knowledge or experience by the Appellant or her niece has not been established. Additionally, the 2011 VA examiner determined that signs and symptoms of pulmonary fibrosis had not been shown continuously. Thus, the lay testimony, even if competent, is outweighed by the examiner's fully supported expert medical opinion. Accordingly, service connection for the cause of the Veteran's death is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection on an accrued benefits basis The Appellant claims entitlement to service connection for pulmonary fibrosis, a gastrointestinal disorder, and anemia, on an accrued benefits basis. Accrued benefits may be paid to the Veteran's surviving spouse, children, dependent parents, and certain other individuals who incur costs on behalf of the Veteran. 38 U.S.C.A. § 5121(a); 38 C.F.R. § 3.1000(a). Accrued benefits are benefits to which an individual was entitled at death under existing ratings or decisions or those based on evidence in the file at the date of death, and are due and unpaid. 38 U.S.C.A. § 5121(a). Evidence in the file includes evidence in VA's possession on or before the date of the Veteran's death, even if not physically located in the claims file. 38 C.F.R. § 3.1000(d). The Appellant's claim for accrued benefits is derivative of the Veteran's claim at the time of his death. See Zevalkink v. Brown, 102 F.3d 1236, 1241-42 (Fed. Cir. 1996). If a Veteran was exposed to Agent Orange during active service, presumptive service connection is warranted for certain specified diseases. 38 C.F.R. §§ 3.307, 3.309. A Veteran is presumed exposed to Agent Orange if he or she had active military, naval, or air service, in the Republic of Vietnam from January 9, 1962 through May 7, 1975, "unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The Veteran has the required service; Agent Orange exposure is presumed. As noted above, if a Veteran was exposed to Agent Orange during active service, service connection is presumed for various disorders, but not pulmonary fibrosis, the Veteran's diagnosed gastrointestinal disorders, or anemia. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). A presumption of service connection based on Agent Orange exposure in the Republic of Vietnam during the Vietnam era is not warranted for various disorders, including respiratory disorders (wheeze or asthma, chronic obstructive pulmonary disorder, and farmer's lung); gastrointestinal, metabolic, and digestive disorders (changes in liver enzymes, lipid abnormalities, and ulcers); and any other condition for which VA has not specifically determined a presumption of service connection is warranted. 75 Fed. Reg. 81332 (Dec. 27, 2010); 75 Fed. Reg. 32540 (June 8, 2010); 72 Fed. Reg. 32395 (June 12, 2007); 68 Fed. Reg. 27630-27641 (May 20, 2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (November 2, 1999); 59 Fed. Reg. 341 (Jan. 4, 1994); 61 Fed. Reg. 41442 (Aug. 8, 1996). Notwithstanding the foregoing, service connection may be established with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167 (1999). Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden, 381 F.3d at 1167. Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may 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). In addition, primary anemia and peptic ulcers may be presumed to have been incurred during service if either first became manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.307, 3.309. The Veteran died on March [redacted], 2005; accordingly, the Board will review only those records associated with the claims file or in VA's possession, constructive or otherwise, as of that date. See 38 C.F.R. § 3.1000(d); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (noting that VA is deemed to have constructive knowledge of certain documents which are generated by VA agents or employees). The Veteran's STRs are silent for a diagnosis of pulmonary fibrosis. Various chest x-rays noted no significant abnormality. The Veteran intermittently reported whooping cough and pneumonia on reports of medical history. Multiple reports of medical examination noted normal lungs and chest, although a 1971 report indicated a history of pneumonia in 1954. VA and private medical records in the 1980s and early 1990s indicate treatment for peripheral vascular disease, treatment for ear, nose, and throat conditions, including hearing loss, and treatment for heart conditions. Records beginning in the early 1990s indicated gastrointestinal complaints. A 1990 VA record noted epigastric symptoms, rule out peptic ulcer disease. A 1993 VA record noted probable intermittent reflux symptoms. Private medical records beginning in 1999 indicate diagnoses of pulmonary fibrosis. A 1999 chest x-ray noted fibrotic changes. A VA record dated in 2000 noted a small hernia, but no gastroesophageal reflux disease (GERD) and an otherwise negative upper gastrointestinal tract examination. Records beginning in 2002 indicate gastrointestinal bleeding, most likely secondary to gastritis. Records dated beginning in 2002 indicate diagnoses of anemia. Records dated in 2003 through 2005 indicate severe anemia requiring blood transfusions. A March 2005 private record determined the anemia was secondary to hemolytic process in a patient with severe pulmonary insufficiency and pulmonary fibrosis. In a September 2004 submission, Dr. TL stated that the Veteran had pulmonary fibrosis and chronic anemia and that it was more likely than not that the end stage lung problem dates back to the Veteran's active duty status. The Board finds that the evidence of record does not support service connection for pulmonary fibrosis, a gastrointestinal disorder, or anemia. At the time of the Veteran's death, there were current diagnoses of pulmonary fibrosis, various gastrointestinal disorders, and anemia. See 38 C.F.R. § 3.303(a), (b); Shedden, 381 F.3d at 1167. But none of these disorders were diagnosed during service or within one year of service discharge. 38 C.F.R. §§ 3.303, 3.307, 3.309; Shedden, 381 F.3d at 1167. The first diagnosis or symptoms of record for the disorders were as follows: 1999 for pulmonary fibrosis; early 2000s for anemia; and early 1990s for gastrointestinal symptoms. Thus, the disorders were over ten years, almost 20 years, and almost ten years after service discharge, respectively. See Mense, 1 Vet. App. at 356. Moreover, the other lay and medical evidence of record does not suggest that the disorders are related to service, as there were no allegations of continuity of symptomatology and no probative evidence linking service and pulmonary fibrosis, gastrointestinal disorders, or anemia. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Shedden, 381 F.3d at 1167. Although a 2004 opinion from Dr. TL indicated that the Veteran's pulmonary fibrosis was linked back to active duty, the Board does not find this opinion probative. See Madden, 125 F.3d at 1481. The opinion lacks probative value as it does not appear to be based upon a review of the relevant evidence and does not provide a supporting explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-04; Stefl, 21 Vet. App. at 124. Accordingly, direct service connection for pulmonary fibrosis, gastrointestinal disorders, and anemia, on an accrued basis is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Appellant's claims, the doctrine is not for application. Gilbert, 1 Vet. App. 49. Burial benefits The Appellant alleges entitlement to service-connected burial benefits. A burial allowance is payable under certain circumstances to cover the burial and funeral expenses of a Veteran and the expense of transporting the body to the place of burial. 38 U.S.C.A. § 2302 (West 2002 & Supp. 2010); 38 C.F.R. § 3.1600 (2012). If a Veteran dies as a result of a service-connected disability or disabilities, a higher amount of burial benefits may be paid. 38 U.S.C.A. § 2307; 38 C.F.R. § 3.1600(a) . As noted above, however, pulmonary fibrosis and pulmonary embolus are not service-connected conditions. Accordingly, service-connected burial benefits are not warranted as a matter of law. ORDER Service connection for the cause of death is denied. Service connection, an on accrued benefits basis, for pulmonary fibrosis, a gastrointestinal disorder, and/or anemia, is denied. Service-connected burial benefits are denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs