Citation Nr: 1304166 Decision Date: 02/06/13 Archive Date: 02/19/13 DOCKET NO. 09-20 458 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to death pension benefits. 2. Entitlement to service connection for an extrapyramidal disorder, for accrued benefits purposes. 3. Entitlement to special monthly compensation (SMC) on account of the need for the regular aid and attendance of another person, for accrued benefits purposes. 4. Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD R. Kessel, Counsel INTRODUCTION The Veteran had active military service from January 1959 to July 1961. The appellant is his widow. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The September 2008 decision denied entitlement to service connection for an extrapyramidal disorder, entitlement to SMC on account of the need for aid and attendance, and entitlement to automobile and adaptive equipment or adaptive equipment only, all for accrued benefits purposes. The decision also denied entitlement to service connection for the cause of the Veteran's death. The appellant was notified of the decision by a letter dated in October 2008, in which the RO also denied entitlement to death pension benefits. The appellant appealed the denials except for the claim for automobile and adaptive equipment or adaptive equipment only. In a March 2012 rating decision, the RO adjudicated other claims that were determined to be pending. At that time, the RO granted entitlement to an earlier effective date of December 1, 1999, for the grant of entitlement to a total disability based on individual unemployability as a result of serviced-connected disabilities (TDIU) and Dependents' Educational Assistance under 38 U.S.C.A. Chapter 35, both for accrued benefits purposes. The RO also denied entitlement to service connection for migraine headaches and an eye disability, both for accrued benefits purposes. Lastly, the RO denied entitlement to Dependency and Indemnity Compensation (DIC) under 38 U.S.C.A. § 1318. The appellant did not appeal the March 2012 decision; thus, the four issues identified on the title page are the issues properly before the Board. The appellant requested a hearing before the Board in a June 2009 substantive appeal. In November 2011, prior to a hearing being scheduled, the appellant notified VA that she wished to withdraw her request for a Board hearing. Under these circumstances, the Board finds that the appellant has been afforded her opportunity for a hearing and that her request to testify before the Board has been withdrawn. 38 C.F.R. § 20.704(e) (2012). In August 2012, the appellant's representative submitted additional evidence in the form of private treatment records and medical research articles. At that time, and again in September 2012, the Veteran's representative waived review of the newly submitted evidence by the agency of original jurisdiction (AOJ). See 38 C.F.R. § 20.1304(c) (2012). Thus, the Board will consider such evidence in the adjudication of this appeal. The decision below addresses the death pension claim and the accrued benefits claims. The issue of entitlement to service connection for the cause of the Veteran's death is addressed in the remand that follows the Board's decision. FINDINGS OF FACT 1. The Veteran did not have active service during a period of war. 2. Based on the evidence of record at the time of his death, the Veteran did not have an extrapyramidal disorder that was attributable to his active military service; nor was it caused or made worse by service-connected disability, including degenerative disc disease and arthritis of the cervical spine. 3. Based on the evidence of record at the time of his death, the Veteran's service-connected disabilities did not result in the need for aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for entitlement to death pension benefits are not been met. 38 U.S.C.A. §§ 101, 1521, 1541 (West 2002); 38 C.F.R. §§ 3.2, 3.3 (2012). 2. The appellant is not entitled to accrued benefits for service connection for an extrapyramidal disorder. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107, 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.1000 (2012). 3. The appellant is not entitled to accrued benefits for special monthly compensation on account of the need for the regular aid and attendance of another person. 38 U.S.C.A. §§ 1114, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.350, 3.352 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board finds that all notification action needed has been accomplished to make a decision as to the death pension and accrued benefits claims. Through an August 2008 notice letter, the RO notified the appellant and her representative of the information and evidence needed to substantiate a death pension claim and a claim for accrued benefits. The Board also finds that the August 2008 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In that letter, the RO notified the appellant that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. The letter also notified the appellant, however, that accrued benefits claims are based on the evidence in VA's possession at the time of the Veteran's death. Consequently, a remand of the death pension and accrued benefits issues for further notification of how to substantiate the claims is not necessary. There is no indication that any additional action is needed to comply with the duty to assist in connection with these three issues. The Veteran's service treatment and personnel records have been obtained and associated with the claims file, as have treatment records and examination reports from the VA Medical Center (VAMC) in Richmond, Virginia. Records from multiple private treatment providers have also been obtained. Notably, unlike the cause of death claim that the Board is remanding, the accrued benefits claims are decided based on the evidence in VA's possession at the time of the Veteran's death. Thus, no additional development is warranted for the two accrued benefits claims. Therefore, VA has properly assisted the appellant in obtaining any relevant evidence for these claims. II. Death Pension Improved death pension under Public Law 95-588 is a monthly benefit payable by VA to a veteran's surviving spouse or child because of a veteran's nonservice-connected death. Basic entitlement exists if the veteran had qualifying wartime service; or the veteran at the time of death was receiving or entitled to receive compensation or retired pay for a service-connected disability based on service during a period of war and the surviving spouse or child meets the net worth requirements specified by regulation and has an annual income not in excess of the applicable maximum annual pension rate specified by regulation. 38 U.S.C.A. § 1541(a) (West 2002); 38 C.F.R. § 3.3(b)(4) (2012). Qualifying wartime service essentially means 90 days or more of active service during a period of war, or 90 continues days of active service that began or ended during a period of war. 38 U.S.C.A. § 1521(j) (West 2002); 38 C.F.R. § 3.3(a)(3). The Veteran's two DD Form 214s document that he had continuous active military service from January 29, 1959, to July 31, 1961. Notably, the "Korean Conflict" ended on January 31, 1955. 38 U.S.C.A. § 101(9) (West 2002); 38 C.F.R. § 3.2(e) (2012). Thus, the Veteran served after that period of war. The next period of war, the "Vietnam Era," began on February 28, 1961, but only for those who served in the Republic of Vietnam. 38 U.S.C.A. § 101(29)(A); 38 C.F.R. § 3.2(f). For all other cases, the Vietnam Era began on August 5, 1964. 38 U.S.C.A. § 101(29)(B); 38 C.F.R. § 3.2(f). Thus, approximately five months of the Veteran's service was during the Vietnam Era only if he had service in the Republic of Vietnam. In regard to the Veteran's possible service in the Republic of Vietnam, his DD Form 214s reflect that he had no foreign service. His personnel file is of record and also does not show foreign service, including any service in Vietnam. During the relevant time period from February 28, 1961, the Veteran's personnel records document that he was stationed at the U.S. Army Garrison in Schofield Barracks, Hawaii. Additionally, in November 2011, the National Personnel Research Center informed VA that there is no evidence in the Veteran's file to substantiate any service in the Republic of Vietnam. In consideration of the evidence, the Board finds that the Veteran did not have active service during a period of war as he served after the Korean Conflict and before the Vietnam Era due to not serving in the Republic of Vietnam. In view of this finding, the Board concludes that entitlement to death pension benefits is not warranted. III. Accrued Benefits Accrued benefits are periodic monetary benefits (other than insurance and servicemen's indemnity) to which an individual was entitled at death under existing ratings or decisions and under laws administered by the VA Secretary, or those based on evidence in the file at date of death and due and unpaid, that shall, upon the death of such individual, be paid to the surviving spouse or other appropriate party. 38 U.S.C.A. § 5121 (West 2002 & Supp. 2012); 38 C.F.R. § 3.1000 (2012). While an accrued benefits claim is separate from a veteran's claim filed prior to death, the accrued benefits claim is derivative of the veteran's claim; thus, an appellant takes the veteran's claim as it stood on the date of death, but within the limits established by law. Zevalkink v. Brown, 102 F.3d 1236, 1242 (Fed. Cir. 1996). For a surviving spouse to be entitled to accrued benefits, the veteran must have had a claim pending at the time of his death for such benefits or else be entitled to them under an existing rating or decision. Jones v. West, 136 F.3d 1296, 1299 (Fed. Cir. 1998). Additionally, a claim for purposes of accrued benefits is based on evidence in the file at the date of the veteran's death. 38 C.F.R. § 3.1000(a). This means evidence in VA's possession on or before the date of death even if such evidence was not physically located in the VA claims folder on or before the date of death. 38 C.F.R. § 3.1000(d)(4). A. Service Connection for Extrapyramidal Disorder The Veteran filed a claim of service connection for an extrapyramidal disorder in January 2008. Although the claim was acknowledged by the RO, it had not yet been adjudicated at the time of the Veteran's death in April 2008. Thus, this service connection claim was a pending claim at the time of his death. See 38 C.F.R. § 3.160(c) (2012). Because the Veteran's claim was not a finally adjudicated claim at the time of his death, an adjudication of the claim for accrued benefits purposes is appropriate. See 38 C.F.R. § 3.1000; Taylor v. Nicholson, 21 Vet. App. 126, 127 (2007). Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, certain chronic diseases, such as paralysis agitans (Parkinson's disease), may be presumed to have been incurred during service if the disease becomes manifest to a compensable degree within one year of separation from qualifying military service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may also be granted for disability that is proximately due to or aggravated by service-connected disease or injury. 38 C.F.R. § 3.310 (2012). In January 2008, the Veteran's representative asserted that service connection was warranted for an extrapyramidal disorder solely on a secondary basis under 38 C.F.R. § 3.310. The representative contended that the Veteran had an extrapyramidal disorder as a result of his already service-connected cervical spine disability. An extrapyramidal disease is any of a group of disorders marked by abnormal involuntary movements, alterations in muscle tone, and postural disturbances and involving lesions of the extrapyramidal tract; included are parkinsonism, chorea, athetosis, and others. Dorland's Illustrated Medical Dictionary at 532 (30th ed. 2003). The evidence of record at the time of the Veteran's death included his service treatment records (STRs). The STRs are devoid of any reference to an extrapyramidal disorder, including Parkinson's disease or paralysis agitans. The records do not note any abnormal involuntary movements, alterations in muscle tone, postural disturbances or lesions. Post-service treatment records dated within one year of the Veteran's separation from service are associated with the claims file. Records from the Commonwealth of Virginia's Mental Hygiene Hospital document that the Veteran was hospitalized in November 1961 due to mental illness. The tentative diagnosis was an acute undifferentiated schizophrenic reaction. This evidence tends to show that the Veteran did not have an extrapyramidal disorder, such as paralysis agitans, that manifested itself during service or within one year of his separation from service. The Veteran was initially seen in the Parkinson's disease clinic at the Richmond VAMC in September 2003. He reported experiencing symptoms of tremors, jerking, and an inability to control his extremities, primarily his feet. The Veteran recalled that he first noticed the problems a few years earlier, but they had begun to progress. After a physical examination and imaging results, the diagnosis was possible cortico basal ganglionic degeneration or possible multiple stroke syndrome on the basis of an MRI scan of 2002. It was noted that the impression was supported by atypical Parkinson's disease. In January 2004, extrapyramidal disorder was listed by VA in the Veteran's medical problem history. Since that time, he was treated on a regular basis for Parkinson's disease-like symptoms at the Richmond VAMC and by private treatment providers. He was variously diagnosed with extrapyramidal disorder, Parkinson's disease, atypical Parkinson's disease, Parkinsonism, atypical Parkinsonism, a questionable neurological disorder, probable Parkinson's disease versus extrapyramidal disorder, and Parkinsonian-like syndrome. This evidence establishes that the Veteran had the claimed disability even if his medical treatment providers were unsure of its exact nature. Although the current disability element of the service connection claim is met, the evidence does not suggest that the Veteran's extrapyramidal disorder was attributable to his military service. None of his treatment providers indicated that his Parkinson's-like problems had their onset during military service, or within one year of separation, or that they were otherwise related to military service. Even the Veteran recalled the onset of symptoms in approximately 1999 or 2000, which was nearly forty years after his discharge from service. Because the preponderance of the lay and medical evidence reflects that the Veteran's extrapyramidal disorder did not have its clinical onset during (or within one year of), or was otherwise related to his active military service, the Board concludes that service connection is not warranted for an extrapyramidal disorder on a direct basis or on a presumptive basis pertaining to chronic diseases. See 38 U.S.C.A. §§ 1101, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. As to the theory of secondary service connection, at the time of the Veteran's death, service connection was in effect for degenerative disc disease and arthritis of the cervical spine, bipolar affective disorder, residuals of a left clavicle fracture with arthritis and surgical scar, and parethesia of the left hand. Similar to direct service connection, none of the Veteran's treatment providers attributed the Veteran's extrapyramidal disorder to his service-connected disabilities. As detailed previously, the treatment providers were equivocal even as to the characterization of the Veteran's problems and the record is light as to the etiology of the problems. Nevertheless, to the extent the origin of the Veteran's problems was addressed, they were attributed to a nonservice-connected condition. In June 2004, one of the Veteran's treating VA physicians indicated that the Veteran had Parkinson's disease secondary to CVA (cerebrovascular accident) to the basal ganglia. In an October 2006 record, Dr. L.R., one of the Veteran's treating physicians, noted that the Veteran's Parkinson's disease or extrapyramidal disorder was secondary to old basal ganglion strokes. Given this information, the most probative competent medical evidence existing at the time of the Veteran's death tends to show that the Veteran's extrapyramidal disorder was caused by his CVA or strokes. Service connection was not in effect for CVA. Thus, the evidence does not reflect that the claimed disability was caused by a service-connected disability. Moreover, the evidence does not show that any service-connected disability aggravated the Veteran's extrapyramidal disorder. In view of this evidence, the Board concludes that service connection is not warranted for an extrapyramidal disorder on a secondary basis. Even though the medical evidence does not show a link between the Veteran's extrapyramidal disorder and a service-connected disability, the appellant and her representative contend that the extrapyramidal disorder was the result of the Veteran's service-connected cervical spine disability. This contention was of record at the time of the Veteran's death. It is not shown, however, that the appellant or her representative possesses the medical expertise necessary to provide a probative opinion on a complex medical matter such as the etiology of the Veteran's extrapyramidal disorder. See, e.g., Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); see also Jandreau, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007) ("[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example a form of cancer."). In the Veteran's case, even the medical providers with specific expertise in the area of Parkinson's disease were uncertain as to all of the aspects of the Veteran's condition. Even so, the extrapyramidal disorder was not related to his service or service-connected disability. Thus, the lay opinions by the appellant and her representative are accorded no probative value due to this being a complex medical matter. For the foregoing reasons, the Board finds that the claim of service connection for an extrapyramidal disorder, for accrued benefits purposes, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). B. SMC on Account of the Need for Aid and Attendance The Veteran filed a claim for SMC on account of the need for aid and attendance in September 2007. Similar to the extrapyramidal claim, although the SMC claim was acknowledged by the RO, it had not yet been adjudicated at the time of the Veteran's death in April 2008. Thus, this SMC claim was a pending claim at the time of his death. See 38 C.F.R. § 3.160(c). Because the Veteran's claim was not a finally adjudicated claim at the time of his death, an adjudication of the claim for accrued benefits purposes is appropriate. See 38 C.F.R. § 3.1000; Taylor, 21 Vet. App. at 127. SMC is payable in addition to the basic rate of compensation for service-connected disability otherwise payable on the basis of degree of disability. See 38 U.S.C.A. § 1114 (West Supp. 2012); 38 C.F.R. § 3.350 (2012). Under 38 C.F.R. § 3.352(a), determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to such conditions as: inability of the claimant to dress or undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without aid; inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from the hazards or dangers inherent in his daily environment. A veteran being "bedridden" will be a proper basis for the determination. "Bedridden" is defined as that condition which, through its essential character, actually requires that the claimant remain in bed. It is not required that all of the disabling conditions enumerated above be found to exist before a favorable rating may be made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352(a) (2012). In March 2007 and September 2007, the appellant stated that the Veteran was incapable of caring for himself because of his advanced dementia, Parkinsonian-like systems, due to nerve damage he sustained from service-connected injury. She indicated that the Veteran was totally dependent on her for total care and could not be left alone. This included: preparing food and drink intake, getting in and out of bed and wheelchair, moving with the wheelchair, ensuring proper medication use, changing clothes and incontinence pads, bathing, monitoring temperature and blood pressure, helping with exercise, and completing daily hygiene activities. The most recent VA treatment record, dated in October 2007, shows that the Veteran was in a wheelchair and that he had a deteriorated ambulation. He had difficulty getting out of his wheelchair and difficulty speaking. One of the Veteran's private treating physicians Dr. L.R., in an August 2007 letter, stated that the Veteran needed a "higher level of care" that is required to establish entitlement to regular aid and attendance allowance. Dr. L.R. indicated that without aid and attendance, the Veteran would require hospitalization, nursing home, or other residential care. Based on the medical records and the appellant's seemingly credible lay statements on the matter, the evidence tends to show that the Veteran generally met the requirements of personal assistance from other set forth in 38 C.F.R. § 3.352(a). The salient question, however, is whether this need for aid and attendance was due to service-connected disability. As noted previously, service connection was in effect for degenerative disc disease and arthritis of the cervical spine, bipolar affective disorder, residuals of a left clavicle fracture with arthritis and surgical scar, and parethesia of the left hand. Although these disabilities combined to make the Veteran unemployable, as he was rated as totally disabled at the time of his death, this rating does not equate to aid and attendance in and of itself. Significantly, in the August 2007 letter, Dr. L.R. attributed the Veteran's inability to care for himself to "advanced dementia, Parkinsonian-like symptoms," which were the same problems to which the appellant pointed. In consideration of this evidence that was in VA's possession at the time of the Veteran's death, the Board finds that the Veteran's service-connected disabilities did not result in the need for aid and attendance of another person. While he did require such assistance, the preponderance of the evidence reflects that the need was on account of nonservice-connected disabilities. Most notably, Dr. L.R.'s August 2007 letter is the most probative piece of evidence as it was authored by an expert who had familiarity with the Veteran's circumstances and it squarely addresses the matter. In view of this finding, the Board concludes that SMC on account of the need for regular aid and attendance is not warranted. For the foregoing reasons, the Board finds that the claim for SMC on account of the need for regular aid and attendance, for accrued benefits purposes, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to death pension benefits is denied. Service connection for an extrapyramidal disorder, for accrued benefits purposes, is denied. Special monthly compensation on account of the need for regular aid and attendance of another person, for accrued benefits purposes, is denied. REMAND The Board finds that the claim of service connection for the cause of the Veteran's death must be remanded for additional development. A surviving spouse of a qualifying veteran who died as a result of a service-connected disability is entitled to receive DIC. 38 U.S.C.A. § 1310 (West 2002 & Supp. 2012); 38 C.F.R. § 3.312 (2012). The death of a veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. The issue involved will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran, including, particularly, autopsy reports. 38 C.F.R. § 3.312(a). The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly 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). Contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1). Generally, minor service-connected disabilities, particularly those of a static nature or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. In the same category there would be included service-connected disease or injuries of any evaluation (even though evaluated as 100 percent disabling) but of a quiescent or static nature involving muscular or skeletal functions and not materially affecting other vital body functions. 38 C.F.R. § 3.312(c)(2). Service-connected diseases 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 were debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. 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 coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4). As noted previously, the Veteran was service connected for degenerative disc disease and arthritis of the cervical spine, bipolar affective disorder, residuals of a left clavicle fracture with arthritis and surgical scar, and parethesia of the left hand. The Veteran's death certificate shows that he died on April [redacted], 2008. The immediate cause of death is listed as cardiac death. No other immediate cause of death was listed. On the death certificate under "other significant conditions contributing to death but not resulting in the underlying cause" was listed either Parkinson's or Parkinsonism in unclear handwriting. Although none of the Veteran's service-connected disabilities is listed on the death certificate, the appellant nevertheless contends that service connection is warranted for the cause of the Veteran's death. In an August 2012 brief, the appellant's representative asserts that the Veteran's Parkinson's disease (or some other disorder misdiagnosed as Parkinson's disease) contributed to his death and was the end result of the medication he was taking to treat his service-connected disabilities. Specifically, the representative notes that the Veteran was prescribed multiple medications, including Prilosec, Trazodone, Paroxetine, Synthroid, Methadone, and Depakote. The representative also submitted two medical research articles that address the connection between transient ischemic attack and Trazodone therapy, as well as sudden death associated with therapeutic levels of Methadone. Although the articles do not pertain to the Veteran's specific case, the representative maintains that the articles support the theory that the treating medications for his service-connected disabilities played a role in his death. Thus, the appellant believes that the Veteran's service-connected cervical spine disability and bipolar disorder did in fact contribute to the Veteran's death in this manner. In DIC claims, VA must make reasonable efforts to provide assistance, to include obtaining a medical opinion. See 38 U.S.C.A. § 5103(d); Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008); DeLaRosa v. Peake, 515 F.3d 1319 (Fed. Cir. 2008). A medical opinion has not yet been obtained in this case. Therefore, the Board finds that the claim must be remanded in order to have a VA physician provide a medical opinion regarding the cause of the Veteran's death, to include consideration of the contentions and theories set forth by the appellant and her representative. As indicated previously, the VCAA requires VA to notify a claimant of the information and evidence needed to substantiate a claim. The United States Court of Appeals for Veterans Claims (Court) has issued a decision regarding the general notice requirements for DIC claims. See Hupp v. Nicholson, 21 Vet. App. 342 (2007). Notice for DIC claims is to 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. Id. at 352-53. In August 2008, the appellant was sent a VCAA notice letter in response to her application for benefits. However, the letter did not fully comply with the notice elements set forth in Hupp, to include listing the conditions for which the Veteran was service connected at the time of his death. Accordingly, on remand, the appellant must be sent a proper VCAA letter informing her of the information and evidence necessary to substantiate her DIC claim in compliance with Hupp. Accordingly, this case is REMANDED to the RO or the Appeals Management Center in Washington, D.C., for the following actions: 1. Send a proper VCAA notice letter to the appellant and her representative. The letter should notify the appellant of the information and evidence necessary to substantiate a claim of service connection for the cause of the Veteran's death. See Hupp, 21 Vet. App. at 352-53. Provide the appellant with: (1) a statement of the conditions for which the Veteran was service connected at the time of his death; (2) an explanation of the evidence and information required to substantiate the claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate the claim based on a condition not yet service connected. In the letter, request the appellant to identify or submit pertinent evidence in support of her claim not already of record, particularly including any relevant medical records near the time period of the Veteran's death. The appellant should be given an opportunity to respond to the notice and any additional information or evidence received should be associated with the claims file. 2. After securing any additional records, forward the claims files and any pertinent evidence in Virtual VA that is not contained in the claims files to a physician for a medical opinion report regarding the cause of the Veteran's death. The physician should provide an opinion on the following inquiries: (a) Is it at least as likely as not (50 percent or greater probability) that one or a combination of the Veteran's service-connected disabilities was the principal or a contributory cause of the Veteran's death? (The Veteran was service connected for degenerative disc disease and arthritis of the cervical spine, bipolar affective disorder, residuals of a left clavicle fracture with arthritis and surgical scar, and parethesia of the left hand.) Consideration should be given to the appellant's theory that the medications for treating the Veteran's service-connected disabilities resulted in problems or conditions, such as Parkinson's disease, that contributed to his death. The two medical research articles that were submitted in August 2012 must be addressed. (b) Is it at least as likely as not (50 percent or greater probability) that a principal or contributory cause of the Veteran's death (e.g., cardiac death, Parkinson's disease/ Parkinsonism) was the result of, or related to, any disease, event, or injury that occurred during his military service? The physician must provide a comprehensive report including complete rationales for all opinions and conclusions reached. 3. After the requested opinion report has been completed, the report should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned to the physician for corrective action. 4. Undertake any other indicated development. 5. Then, re-adjudicate the appellant's claim of entitlement to service connection for the cause of the Veteran's death. If the benefit sought is not granted, furnish the appellant and her representative with a supplemental statement of the case and afford them the requisite opportunity to respond before the record is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until she is otherwise notified by VA, but she has the right to submit additional evidence and argument on the matter the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs