Citation Nr: 1304610 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 09-46 885 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for the cause of the Veteran's death. 2. Whether there was clear and unmistakable error (CUE) in a July 14, 1995 rating decision which denied service connection for major depression REPRESENTATION Appellant represented by: Drew Early, Attorney WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran had active service from June 1965 to June 1985. He died in May 2007. The appellant is the Veteran's widow. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) located in Atlanta, Georgia. The appellant testified at a Board hearing before the undersigned Veterans Law Judge in October 2012 via video conference from the RO. A copy of the transcript of that hearing is of record. In a February 2011 rating decision, the RO determined that there was no CUE in a July 14, 1995 rating decision which denied service connection for major depression. A notice of disagreement was received that same month. The issue of whether there was CUE in a July 14, 1995 rating decision which denied service connection for major depression is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At the time of the Veteran's death, service connection was in effect for diabetes mellitus (DM) with peripheral neuropathy, rated as 40 percent disabling; gout with osteoarthritis changes in the metatarsophalangeal joint of the left and right great toes, rated as 40 percent disabling; right facial nerve, postoperative, acoustic neuroma with dry eye and lagophthalmos, rated as 30 percent disabling; degenerative joint disease with degenerative disc disease of L4-5, status post laminectomy for spinal stenosis, rated as 20 percent disabling; profound hearing loss, right ear, and moderate high frequency hearing loss of the left ear, rated as 10 percent disabling; balance problem and disorientation dizziness due to right facial nerve post operative neuroma, rated as 10 percent disabling; arthritis of the hands, rated as 10 percent disabling; each chondromalacia patella of the right knee with early degenerative arthritis, rated as 10 percent disabling; hypertension, rated as 10 percent disabling; sinusitis, rated as noncompensable; mastoid and occipital bone loss, rated as noncompensable; and seventh rib dysplasia, rated as noncompensable; and the Veteran was receiving a total disability rating based on individual unemployability (TDIU). 2. Probative evidence shows that the Veteran's major depression was attributable to service, although not service-connected during his lifetime. 3. The Certificate of Death reflects that the Veteran died in May 2007. The immediate cause of death was intraoral gunshot wound, perforating head, as a result of suicide. There were no significant conditions contributing to death. 4. Probative evidence shows that the Veteran's suicide was etiologically related to his major depression. CONCLUSION OF LAW A disability due to disease or injury incurred in service contributed substantially or materially to the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1131, 1310, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303. 3.304, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION There has been a significant change in the law with the enactment of the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. The appellant's claim is being granted. As such, any deficiencies with regard to VCAA are harmless and nonprejudicial. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. In order to establish service connection for the cause of the Veteran's death, applicable law requires that the evidence show that a disability incurred in or aggravated by his service either caused or contributed substantially or materially to his death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. In order to constitute the principal cause of death the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). A 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). 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 resulting 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. 38 C.F.R. § 3.312(c)(3). 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. Id. There are primary causes of death that 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). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability.. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). If chronicity (i.e., permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). See also Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Under § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Savage v. Gober, 10 Vet. App. 494-97 (1997); Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see also Hickson v. West, 12 Vet. App. 247, 253 (1999) (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing entitlement to service connection). To establish a showing of chronic disease in service, or within a presumptive period per § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. In-service notation of a condition does not require medical evidence where "the condition is of a type as to which a lay person's observation is competent." Savage, 10 Vet. App. at 497. However, although prong (3) does not require medical nexus evidence, "because it would not necessarily follow that there is a relationship between any present disability and the continuity of symptomatology demonstrated, medical evidence is required to demonstrate such a relationship unless such a relationship is one as to which a lay person's observation is competent." Id (citations omitted). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, 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, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). Savage, 10 Vet. App. 488, 494-97. When, for example, 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 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, 310 (2007). So medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence" such as actual treatment records). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must additionally determine whether the evidence also is credible, as only then does it ultimately have probative value. See Layno (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). Also, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the nonservice-connected disease or injury. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and competent evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit Court, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran or claimant, and the Veteran or claimant's demeanor when testifying at a hearing when he/she has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604(Fed. Cir. 1996). Service connection may be granted for a disease first diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any issue material to the determination is resolved in the claimant's favor. 38 C.F.R. § 3.102. The Veteran died in May 2007. At the time of the Veteran's death, service connection was in effect for DM with peripheral neuropathy, rated as 40 percent disabling; gout with osteoarthritis changes in the metatarsophalangeal joint of the left and right great toes, rated as 40 percent disabling; right facial nerve, postoperative, acoustic neuroma with dry eye and lagophthalmos, rated as 30 percent disabling; degenerative joint disease with degenerative disc disease of L4-5, status post laminectomy for spinal stenosis, rated as 20 percent disabling; profound hearing loss, right ear, and moderate high frequency hearing loss of the left ear, rated as 10 percent disabling; balance problem and disorientation dizziness due to right facial nerve post operative neuroma, rated as 10 percent disabling; arthritis of the hands, rated as 10 percent disabling; each chondromalacia patella of the right knee with early degenerative arthritis, rated as 10 percent disabling; hypertension, rated as 10 percent disabling; sinusitis, rated as noncompensable; mastoid and occipital bone loss, rated as noncompensable; and seventh rib dysplasia, rated as noncompensable; and the Veteran was receiving a TDIU. The Certificate of Death confirms that the Veteran died in May 2007. The immediate cause of death was intraoral gunshot wound, perforating head, as a result of suicide. There were no significant conditions contributing to death. An autopsy and police report confirmed these findings. The police report noted that the appellant stated that prior to his death, the Veteran had become more depressed and was acting in an angry manner. In testimony provided at her hearings and in correspondence of record, the appellant contends that the Veteran committed suicide due to a psychiatric disability which began during service and was later also aggravated by his many service-connected disabilities, particularly his DM and with peripheral neuropathy, as well as other disabilities causing pain. As already explained, competent lay evidence may establish the presence of observable symptomatology and, in certain circumstances, it may provide a basis for establishing service connection. See Barr. Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. Jandreau; see Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan; see also Rucker and Layno. The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Buchanan at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. The appellant is competent to state that the Veteran had been depressed for many years and suffered due to pain from his service-connected disabilities, as those statements were based on her own observations. However, the appellant is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, VA has obtained a medical opinion and the appellant has also furnished two medical opinions to resolve the complex matters in this case. Turing first to the STRs, they reflect that the Veteran was treated for problems sleeping in 1970 and a possible nervous condition in 1972. In August 1974, he was psychiatrically evaluated. He reported having apprehension and anxiety when he was working and felt that he was under stress. The stress issues appeared to exacerbate his gout. It was recommended that the Veteran not be put in situations where an exacerbation might occur. In 1977, the Veteran was diagnosed with transient situational disturbance. In an undated report, it was noted that the veteran had frequent trouble sleeping, depression/excessive worry, and nervous trouble. Post-service, in January 1994, the Veteran was psychiatrically hospitalized. At that time, it was noted that he had a history of depressive episodes which had occurred twice since 1970 with a suicide attempt in 1994. He was admitted with a diagnosis of reactive depression. He was released after several days and transferred to psychiatric services for treatment of his depression. Subsequent VA records noted that the Veteran should reduce his stress levels. In March 1994 correspondence, the Veteran indicated that he had major depression. He stated that because of his vision problems. He was depressed and tried to kill himself. The Veteran's psychiatric disability thereafter continued. There are three medical opinions regarding the Veteran's cause of death. The first, dated in August 2009, was provided by a VA psychiatrist. The examiner indicated that the Veteran's diagnosis prior to death was major depressive disorder, severe. She reported that it was certainly difficult to state with any degree of medical certainty what factors contributed to an event like a suicide, and with what weight each factor might have had toward the outcome. In instances such as these, she said that it was often useful to look at the evidence recorded closest in time to the event. The examiner opined that the Veteran's incident in the 1970's was not an episode of major depression and was probably not related etiologically to later depression. Rather, the episode would likely have been an adjustment disorder, given that it resolved spontaneously when the stressor was removed. Whether and to what degree or extent that the Veteran's suicide was related to service she stated was less clear. She further stated that based on the record, it was reasonable to assume that the Veteran was having an episode of major depression at the time he died. She noted that the appellant had indicated to the police that the Veteran's depression was related to his peripheral neuropathy, which she noted, had not been service-connected. However, the Board notes that the Veteran was in fact service-connected for peripheral neuropathy. The examiner also referred to nonservice-connected disabilities which were plaguing the Veteran when he died. She related that there were a number of confounding additional features in this case, such as the presence of worsening marital problems and health conditions, including the Veteran's concern that he was developing Alzheimer's disease. In addition, the Veteran had been self-medicating with alcohol which she thought would have worsened his depression and sleep. Based on the information of record, it was the opinion of the examiner that the Veteran's depression that resulted in his suicide was not related etiologically to the inservice adjustment disorder. It was further her opinion that with his diverse etiological factors, it would be resorting to mere speculation to state to a degree of medical certainty that the Veteran's suicide and any preexisting depression were due to a service-connected illness. The second medical opinion provided by C.N.B. M.D., indicated that a review of the Veteran's records was accomplished, including the Certificate of Death. With regard to pertinent history, the physician noted the Veteran's service-connected disabilities, including DM with painful peripheral neuropathy of all four extremities. He also noted that the Veteran was depressed while he was in service as his records showed that the Veteran had a change of assignments due to depression. It was this physician's opinion that the Veteran was clinically depressed due to his chronic DM prior to his demise as the record showed that he would not get out of bed, would not enjoy any daily activities, did not work, did not eat a regular diet, and was taking pain medication. He stated that DM was linked to depression and cited and provided medical treatise evidence as support for that conclusion. He went on to state that it was his opinion, considering every possible sound medical etiology/principle, to at least the 50 percent level of probability, that the Veteran's suicide was due to his service-connected disabilities, including DM, with chronic pain and depression. He provided the following rationale: the Veteran entered service without any doctor diagnosed illnesses; he developed depression during service as shown in the STRs; he developed DM in service which was service-connected; he had post-service peripheral neuropathy (due to DM) which was very painful: he very likely had major depression secondary to his chronic illness; and because chronic pain, chronic illness, hopelessness, anhedonia, and major depression were all well-known risk factors for suicide and the Veteran had all five of those. The physician also provided medial treatise evidence as support for that finial conclusion. The physician also indicated that the record did not support another more plausible etiology for the suicide other than major depression that this opinion was consistent with medical literature; and that the opinion represented sufficient and competent medical data and was sufficiently comprehensive in nature. Dr. B. also reviewed the VA examiner's opinion, but opined that it was incorrect because she did not discuss medical literature that had been submitted by the appellant (which discussed suicides among male veterans); she did not discuss the medical literature provided by Dr. B.; she did not provide any independent literature for support of her decision; she limited her opinion to an adjustment disorder from service or a pre-existing depression; she did not adequately discuss whether the Veteran's major depression was likely secondary to his service-connected disabilities; she did not provide her curriculum vitae; and her opinion was inconsistent with the clinical objective data/tests or the appellant's lay statements. The third opinion was provided by D.E.S., M.Ed., Ph.D., who also reviewed the Veteran's medical records and history. This psychologist indicated that the STRs clearly documented the presence of depression during service, citing to inservice psychiatric evaluations in November 1972 and February 1977. Further, he opined that the Veteran's depression was also secondary to his service-connected disabilities. The examiner noted that the record showed repeated attempts to label the Veteran's depression as an "adjustment" disorder because it was triggered by job stress. However, he stated that if the depression was primary and exacerbated by job stress, it was not an adjustment issue, but rather a problem functioning in the environment due to depression. He further explained that an adjustment disorder only lasts six months after a stressor is removed for diagnosis. A major depressive disorder diagnosis was noted in 1994. The psychologist indicated that the Veteran had a history of cyclical depression which was exacerbated by medical and work stress. In addition, the stress was present due to his unemployability which in turn exacerbated the depression. He also stated that DM is comorbid with depression as well as statin drugs were also premorbid with depression (medical literature was cited for support). In addition, it was further noted that the Veteran's sleep condition which could have been a side effect of his depression and was not properly controlled. In conclusion, Dr. S. found that it was highly likely that the Veteran's medical diagnosis and treatment during and after his active service did not meet the standard of care for his mental health conditions and it was highly likely that the Veteran had a major depressive disorder, current, during his military service. In addition, his service-connected physical illnesses contributed to his worsening mental health condition and led directly to his death. Thus, essentially, he opined that service connection for depression was appropriate on either a direct basis or secondary basis. As such, service connection for the cause of death was also in order. The Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, all of the examiners are competent to provide medical opinions. While they have various medical qualifications, they are all qualified to render an opinion, particularly since they all appear to have relied on an accurate medical history. Turning initially to the matter of whether the Veteran's depression was etiologically related to service, the Board finds that there is sufficient evidence establishing that there was in fact this etiological connection. The STRs recorded psychiatric complaints, including depression. Post-service, in January 1994, the Veteran was psychiatrically hospitalized. The notation at that time indicated that the Veteran had a history of depressive episodes which had occurred twice since 1970. The Board finds probative the indication that the first episode occurred during service. The VA examiner opined that the Veteran had an adjustment disorder during service which was not related to depression which was present and etiologically responsible for his suicide, causing death. However, Dr. S. provided an adequate explanation of why the Veteran had depression and not an adjustment disorder. His opinion is also consistent with the aforementioned STR which noted depression as well as the 1994 report which indicated that the first episode of depression occurred during service and the second episode resulted in an unsuccessful suicide attempt in 1994. In any event, the evidence is at least in equipoise as to whether the Veteran's psychiatric illness during service was in fact depression which remained during his lifetime, eventually causing his suicide. Thus, the evidence in this case is so evenly balanced so as to allow application of the benefit-of- the-doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Since the Board finds that there is sufficient evidence to establish an etiological connection between the Veteran's depression and service, there is no need to consider whether secondary service connection is in order under 38 C.F.R. § 3.310(a), although the Board notes that there is sufficient positive evidence to also support that theory of service connection. All of the examiners who provided an opinion advance that the Veteran had major depression which resulted in his death, so there is no countervailing opinion in that regard. Accordingly, the remaining matter to be resolved, whether the Veteran's depression, which was attributable to service, played any role in causing/contributing to cause his death; contributed substantially or materially to death, or aided or lent assistance to the production of death, is also resolved in the appellant's favor as the preponderance of the evidence establishes that the Veteran's major depression resulted in his suicide attempt, the cause of his death. Accordingly, service connection for the cause of the Veteran's death is granted. ORDER Service connection for the cause of the Veteran's death is granted. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the appellant's claim so that the appellant is afforded every possible consideration. As noted in the introductory portion of this decision, the Veteran has submitted a notice of disagreement as to the issue of whether there was CUE in a July 14, 1995 rating decision which denied service connection for major depression. As such, a statement of the case must be issued. The failure to issue a statement of the case is a procedural defect requiring a remand. Manlincon v. West 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: The Veteran should be sent a statement of the case as to the issue of whether there was CUE in a July 14, 1995 rating decision in accordance with 38 U.S.C.A. § 7105 and 38 C.F.R. §§ 19.29, 19.30. If the Veteran perfects his appeal by submitting a timely and adequate substantive appeal on this issue, then the claim should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs