Citation Nr: 1305689 Decision Date: 02/15/13 Archive Date: 02/21/13 DOCKET NO. 10-08 318 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL Appellant and the Veteran's grandson ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active service from March 1948 to March 1952, including in the Korean Conflict. He died in July 2007. The Appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which denied the Appellant's claim of service connection for the cause of the Veteran's death. Although the Appellant did not disagree with this decision, she submitted evidence and information relevant to her claim within 1 year of the December 2007 rating decision which rendered it non-final for VA purposes under 38 C.F.R. § 3.159(b). See Buie v Shinseki, 24 Vet. App. 242, 251-52 (2011) (explaining that, when statements are received within one year of a rating decision, the Board's inquiry is not limited to whether those statements constitute notices of disagreement but whether those statements include the submission of new and material evidence under 38 C.F.R. § 3.156(b)). The RO subsequently readjudicated the claim in an April 2008 rating decision. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. A Travel Board hearing was held at the RO in March 2012 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran had active service from March 1948 to March 1952, including in the Korean Conflict. He died at age 77 in July 2007. 2. The immediate cause of death, as listed on the Veteran's death certificate, was gastrointestinal bleeding of 1 to 2 days duration, due to esophageal dysplasia of 4 years duration as a consequence of Barrett's esophagus of 15 years duration. Another significant condition contributing to his death but not resulting in the underlying cause of death was Alzheimer's disease. Also, tobacco use was listed a probably contributing to his death. No autopsy was performed. 3. At the time of his death the Veteran was service-connected for post-traumatic stress disorder (PTSD), rated 50 percent disabling; residuals of a gunshot wound of the left arm, rated 20 percent disabling; residuals of a gunshot wound of the left thigh, rated 10 percent disabling; and noncompensable ratings were assigned for residuals of an incompletely healed fracture of the left lower humerus and for residuals of malaria. There was a combined disability rating of 60 percent. 4. The Veteran's fatal esophageal dysplasia, Barrett's esophagus, and Alzheimer's disease were not incurred or aggravated in service, did not manifest until many decades after service, and were not causally related to an incident of service nor were they caused or aggravated by service-connected disabilities or medication prescribed by VA. 4. The Veteran did not have any disability of service origin or related to service-connected disorders that contributed substantially and materially to his death, or hastened it, or otherwise aided or lent assistance to it. CONCLUSIONS OF LAW 1. The Veteran's terminal esophageal dysplasia, Barrett's esophagus, and Alzheimer's disease were not incurred in or aggravated by active service, did not manifest to a compensable degree within one year after service, and so may not be presumed to have been so incurred, and were not proximately due to or aggravated by a service-connected disability or any combination of service-connected disabilities. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) and (b) (2012). 2. A service connected disability nor service-connected disabilities cumulatively did not cause or contribute substantially or materially to cause the Veteran's death. 38 U.S.C.A. §§ 1310, 5107 (West 2002); 38 C.F.R. § 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONs I. Veteran Claims Assistance Act of 2000 VA has a duty to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, et seq (effective November 9, 2000) (Veteran Claims Assistance Act of 2000 (VCAA)); see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159. This notice was intended to be provided prior to an initial adjudication of a claim. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (Pelegrini II). However, it may be provided thereafter is there is not prejudice, e.g., prior to a subsequent readjudication, even in a Statement of the Case (SOC) or Supplemental SOC. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (Pelegrini II). See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed.Cir. 2003). By letter dated in March 2012, after the initial adjudication of the claim, the RO advised the appellant of the evidence needed for claim substantiation. 38 U.S.C.A. § 5103(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). That letter explained what evidence VA would obtain or assist in obtaining and what information or evidence the claimant was responsible for providing. 38 U.S.C.A. § 5103(a). For a claim, as here, pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 was amended to eliminate the requirement that VA also request that the submission of evidence in the claimant's possession that might help in claim substantiation. See 73 Fed.Reg. 23353 (Apr. 30, 2008). The letter also complied with the required mandated by Dingess v. Nicholson, 19 Vet. App. 473 (2006) that notice be given as to all five elements of a service connection claim which are: (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. In Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007), the Court held that in the context of a claim for DIC benefits, the section 5103(a) notice must include: (1) a statement of the conditions, if any, for which the 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. The March 2012 letter also provided this notice. Moreover, as the claim is denied, no disability rating and effective date will be assigned as a matter of law. Therefore, there can be no possibility of any prejudice to the Veteran with respect to any defect in the VCAA notice required under Dingess, at 19 Vet. App. 473. See VAOPGCPREC 8-2003 (Dec. 22, 2003); Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007) and Bernard v. Brown, 4 Vet. App. 384, 394 (1993). As required by 38 U.S.C.A. § 5103A, VA has made reasonable efforts to identify and obtain relevant records for claim substantiation. The Veteran's service treatment records (STRs) have been obtained. Also, his VA treatment records are on file. The appellant and the Veteran's grandson testified in support of the claim at an RO hearing before the undersigned VLJ in March 2012. Effective June 18, 2012, as to Board decisions issued on or after August 23, 2011, 38 C.F.R. § 3.103(c)(2) (setting for duties to fully explain the issues and to suggest the submission of evidence that may have been overlooked) was amended to specifically state that the conduct of Board hearings is governed by 38 C.F.R. § 20.706 which requires only that the presiding Veterans Law Judge assures that the course of the hearing remains relevant to any issue. The case was remanded in September 2012 to attempt to obtain records of the Social Security Administration (SSA) concerning any possible award of disability payment. See Golz v. Shinseki, 590 F.3d 1317, 1320-1321 (Fed. Cir. 2010). However, upon being contacted, the SSA indicated that no records were available. On September 26, 2012, the appellant was sent a notification letter asking her to submit additional evidence in support of her appeal for service connection for the cause of the Veteran's death. In October 2012, she was again contacted and asked if she had any of the Veteran's SSA records prior to his death, and she reported that she did not have any records. Later in October 2012, a Memorandum of the Formal Finding of the Unavailability of the Veteran's SSA records was completed and placed in his claims file. And all this was in substantial compliance with the Board remand. Substantial, rather than absolute or strict, remand compliance is the appropriate standard for determining remand compliance under Stegall v. West, 11 Vet. App. 268 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The appellant and her representative have placed in the claims file information obtained from the internet which address the matter of gastrointestinal symptoms in relation to psychiatric disability, and in particular to PTSD. Also, VA medical opinions addressing the relevant matters have been obtained. The adequacy of one opinion was questioned at the hearing as being speculative. As a result, another expert opinion was requested from VA medical personnel (hereafter VHA opinion). See 38 C.F.R. § 20.901(d) and 20.903(a) (2012). The adequacy of the VHA medical opinion has not been challenged. As to this, the Board is entitled to assume the competence of VA medical personnel and the adequacy of a VA medical opinion unless it is challenged. See Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010); Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); and Hilkert v. West, 12 Vet. App. 145, 151 (1999). Also, the competence of the VA physician providing the VHA opinion is not challenged. At the hearing the appellant indicated that she did not believe that all of the Veteran's VA medical records were in the claim file. However, upon review of the claim file, and the CAPRI records contained in Virtual VA, it appears that all of the Veteran's VA medical records are available for review. As there is neither an indication that the appellant was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board concludes that there has been full VCAA compliance. II. Background The Veteran's STRs show that in September 1951 he had chills and fever with anorexia, nausea, vomiting, fatigue, and malaise. The diagnosis was malaria. The STRs are otherwise negative for signs, symptoms, complaints, history, treatment or diagnosis of any gastrointestinal disability. VA treatment records show that in 1998 there were diagnoses of a hiatal hernia, Barrett's esophagus, and a colon adenoma. In 1999 it was noted that he had stopped using tobacco, i.e., stopped smoking cigarettes, 30 years earlier. The Veteran died at age 77 in July 2007. The immediate cause of death, as listed on his death certificate, was gastrointestinal bleeding of 1 to 2 days duration, due to esophageal dysplasia of 4 years duration as a consequence of Barrett's esophagus of 15 years duration. Another significant condition contributing to his death but not resulting in the underlying cause of death was Alzheimer's disease. Also, tobacco use was listed a probably contributing to his death. No autopsy was performed. At the time of his death the Veteran was service-connected for post-traumatic stress disorder (PTSD), rated 50 percent disabling; residuals of a gunshot wound of the left arm, rated 20 percent disabling; residuals of a gunshot wound of the left thigh, rated 10 percent disabling; and noncompensable ratings were assigned for residuals of an incompletely healed fracture of the left lower humerus and for residuals of malaria. There was a combined disability rating of 60 percent. A VA medical opinion was obtained in March 2008 which noted that details of the immediate events leading to the Veteran's death were not apparent from a review of the claim file. The current claim focused on the presence of PTSD which might be an aggravating factor in the Veteran's gastrointestinal disturbance. A record review also revealed that the Veteran had been diagnosed and treated for a bipolar disorder, beginning in 1999. Barrett's esophagitis was diagnosed by an EGD in July 1998 and his proton pump inhibitor (lansoprazole) was increased to 30 mg b.i.d. He apparently continued on the proton pump inhibitors until his death. The Veteran had been diagnosed with a bipolar disorder, PTSD, as well as Barrett's esophagitis and associated esophageal dysplasia. The opining physician stated that he was not able to delineate the etiology of the Veteran's gastrointestinal bleed which led to his death but which was presumptively related to his esophageal disease. The DSM-IV did state that "PTSD may be associated with increased rates of somatic complaints and, possibly general medical conditions." The opining physician was not aware of any specific link with PTSD in terms of it being an etiologic basis for Barrett's esophagitis or GERD (gastroesophageal reflux disease). Therefore, it was felt that it would be pure speculation to state that there was such a link. A computer search for literature did not reference any publications that referred to an etiologic link of PTSD to esophageal conditions per se. On the other hand, it was possible that the Veteran's long-term care providers may have noted a link between stress, anxiety, and aggravation of his esophageal symptoms. However, it was the opining physician's understanding that a good adherence to proton pump inhibitor medication was highly effective in decreasing the incidence of esophageal ulceration and/or bleeding. At the March 2012 travel Board hearing the appellant testified that when she married the Veteran, 20 years prior to his death, he was not service-connected for PTSD. Page 2 of that transcript (T2). He had been service-connected for PTSD about 7 years prior to his death. When they were married he had gastrointestinal problems. When he ate, sometimes his nerves were so bad that he would gag. He had never mentioned to her what he thought was causing his gastrointestinal symptoms but he knew he had problems with PTSD and had been afraid of the possibility that he might be placed on a locked ward. T3. The Veteran's grandson testified that the Veteran had been disturbed by memories of his military experiences and, sometimes, when he ate he would shake. T5. The appellant testified that the Veteran had taken VA prescribed medication for gastrointestinal problems. He had had surgery but, apparently, not all of the cancer had been removed and, so, it had recurred. She was aware of the negative medical opinion rendered by a VA physician in this case. It was pointed out that no outside physician had been requested to review the case to obtain another opinion that might not be speculative in nature as to whether the medications the Veteran was taking for his gastrointestinal problems or for this PTSD might have had a bearing on his death. T6. It was requested that an outside medical opinion be obtained as to whether or not the Veteran's PTSD or any medication for PTSD was in any way related to the cause of his death. T7. It was indicated that information on file which was obtained from the internet tended to support such a possibility. T7. The appellant stated that the Veteran had not died while hospitalized but, rather, had died en route to a VA hospital. T10. The appellant stated that the Veteran was taking a lot of medications for his stomach and his PTSD. He was also taking aspirin for heart troubles. T12. No physicians had told her that the Veteran's medications, even in combination, had led to or hastened his death. T15. He had resisted seeking VA treatment in the last few days and weeks immediately prior to his death. T15 and 16. The appellant and her representative have submitted into the record literature obtained from the internet, some of which was apparently obtained from VA websites. In May 2012 an opinion was requested from a VA expert. The July 2012 VHA opinion addressed several matters. It was requested that the gastrointestinal disabilities the Veteran had during his lifetime be identified and address whether it was as likely as not that the disability(ies) was or were related to his military service, including treatment for parasites. In response, it was noted that that it had been reported that he had been treated for intestinal parasites in April 1951. He had had a hiatal hernia, GERD, Barrett's esophagus, and tubular adenoma. His gastrointestinal diagnoses in his lifetime included GERD complicated by Barrett's esophagus which ultimately resulted in esophagectomy, diverticulosis, tubular adenoma, chronic constipation, and intestinal parasitosis. Since his parasitosis was identified and treated during his active service, it was service related. The remaining gastrointestinal diagnoses were unlikely to have been related to his service. More specifically, the remaining gastrointestinal diagnoses were unlikely to have been related to his service-related parasitosis. As to whether it was as likely as not that his post service gastrointestinal problems were due to PTSD or medications for PTSD, the answer was no. The rationale was that stress in general could cause gastrointestinal symptoms, such as heartburn, and PTSD could probably contribute, although basis references did not indicate that PTSD was a common cause of gastrointestinal symptoms. There was no evidence, nor any reason to think, that the likelihood of PTSD contributing to Barrett's esophagus would approach a 50% standard. The remaining gastrointestinal diagnoses were not plausibly related to PTSD. PTSD had a modest incidence of gastrointestinal side effects and the VA physician was unaware of any evidence that they were related to the development of Barrett's esophagus. Any contribution that the medications might provide would not approach the 50% standard. The other gastrointestinal diagnoses were not plausibly related to the medications. As to the question of whether the Veteran's service-connected disabilities, including multiple residuals of gunshot wound, malaria, and PTSD, contributed to his death, the answer was no. The answer was necessarily speculative because no autopsy was done and the cause of death was not known. The cause of death was presumed to be gastrointestinal bleeding because of several days of abdominal pain prior to collapsing and vomiting coffee ground material at the time of his death in July 2007. There was little to support the diagnosis, as he died shortly after arriving in the emergency room, and many other causes were possible. Even if gastrointestinal bleeding contributed to his death, the cause of the bleeding was unknown. None of his service-connected disabilities would typically cause gastrointestinal bleeding. As to the question of whether PTSD medications contributed to the Veteran's death, the answer was also no. As with the prior question, the answer was speculative since the cause of death was unknown. The medications (as listed by in the VHA opinion) suggested that the Veteran had longstanding stable doses of his PTSD medications, and they would be unlikely to cause gastrointestinal bleeding in any event. As to the question of whether the fatal gastrointestinal bleeding was caused by his postservice gastrointestinal problems, including Barrett's esophagus, the answer was no. It was reported that, as noted previously in the VHA opinion, it was not clear whether he had a significant gastrointestinal bleed at the time of his death, and it was not known what caused the bleeding. Barrett's esophagus did not typically cause gastrointestinal bleeding, and whatever risk might occur was presumably eliminated by his esophagectomy. Gastrointestinal bleeding was not a common long-term complication of an esophagectomy. III. Laws and Regulations DIC is awarded if a service-connected disability was either the principal or a contributory cause of the veteran's death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. A principal cause of death is one which, alone or jointly with another disorder, was the underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which, though not related to the principal cause, contributed substantially or materially or combined with other disorders to cause death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). DIC is also awarded if the veteran's death can be service connected. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. That is, service connection for the cause of the Veteran's death is granted, post mortem, and DIC is awarded, if the evidence shows that disease or injury actually incurred or aggravated in service, though service connection had not been granted for the disease or injury prior to the veteran's death, was either the principal or a contributory cause of death. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection for current disability, or for disability that causes or contributes to cause death, requires evidence of an etiologic relationship between events in service, or an injury or disease incurred there, and the death or current disability. Cuevas v. Principi, 3 Vet. App. 542, 548 (1992), citing Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). To establish service connection for the cause of a veteran's death, due to a cause not already service-connected, the evidence must show that a disability that either was incurred in or aggravated by service, or which was proximately due to or the result of a service-connected condition, was either a principal or contributory cause of death. 38 U.S.C.A. §§ 1101, 1112, 1113, 1310; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a), 3.312(a); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). For a service-connected disability to be the principal cause of death, it must singularly or jointly with some other condition be the immediate or underlying cause of death, or be etiologically related thereto. 38 C.F.R. § 3.312(b). For a service-connected disability to be a contributory cause of death, it must be shown that it contributed substantially or materially, that it combined to cause death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Furthermore, with chronic disease shown as such in service so as to permit a finding of service connection, 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). For the showing of chronic disease in service there is required 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." Id. Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id.; See also Savage v. Gober, 10 Vet. App. 488, 495 (1997). Service connection is also possible for any disease initially diagnosed after discharge from service when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain conditions, including organic diseases of the nervous system, will be presumed to have been incurred in service if manifested to a compensable degree within 1 year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Disability that is proximately due to or the result of a service-connected disorder shall be service-connected; also service connection will also be granted for aggravation of a non-service-connected condition by a service-connected disorder, although compensation is limited to the degree of disability (and only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b). IV. Analysis It is not shown or contended that the Veteran's symptoms in 1951, including nausea and vomiting were anything other than symptoms of his service-connected malaria. It is not otherwise shown or contended that any gastrointestinal disability, which it is asserted was a terminal cause of the Veteran's death, was incurred during active service. It is alleged that the Veteran died of chronic gastrointestinal disability which caused fatal gastrointestinal bleeding. As to the cause of the fatal gastrointestinal bleeding, it was postulated at the hearing that his service-connected PTSD or medications for PTSD or possibly other medications prescribed by VA may have, in some manner, contributed to or hastened his death. This speculation was set for the by the appellant and her representative. When taken together with information on file which was obtained from the internet, these allegations warranted obtaining medical opinion in this case. However, the speculations by the appellant and her representative, who are laypersons, does not constitute competent evidence in this case. This was essentially conceded at the hearing when it was requested that an additional expert medical opinions be obtained. Lay evidence is competent when a condition can be identified by a layperson. See 38 C.F.R. §§ 3.159(a)(1) and (2) (defining competent medical and lay evidence) and 3.307(b) (as to chronicity and continuity of symptoms lay evidence should describe material and relevant facts observed and not merely conclusions based upon opinion). Lay evidence may, in some circumstances, establish a medical diagnosis, causation or etiology, i.e., when a layperson (1) is competent to identify the medical condition, (2) is reporting a contemporaneous medical diagnosis, or (3) describes symptoms at the time which supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir. 2009) (overruling the broad holdings in Buchanan v. Nicholson, 451 F.3d 1331 (Fed.Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (2007) that competent medical evidence is required when the determinative issues if either medical etiology or a medical diagnosis); see also King v. Shinseki, 700 F.3d 1399 Fed.Cir. 2012); 2012 WL 6029502 (C.A.Fed.) (confirming that Davidson, Id., overruled the broad holdings noted above in Buchanan, Id., and Jandreau, Id.). Here, the nexus between the Veteran's death and his military service, his service-connected disabilities, and any medications prescribed by VA is not a simply matter capable of being proven by lay evidence. Rather, medical education, training, and expertise are required to knowledgably render an opinion as to these matters. Moreover, the appellant has not stated, testified or suggested that there is any supporting, i.e., favorable medical opinion or diagnosis. Thus, none of the three circumstances delineated above exists which would make lay evidence competent in these circumstances. Accordingly, the only competent evidence is the two VA medical opinions. Unfortunately, each opinion was unfavorable and, so, they only refute rather than support the claim. Both opinions indicate that while the Veteran died from gastrointestinal bleeding, but it was unclear whether the Barrett's esophagus was actually the underlying cause of the fatal gastrointestinal bleeding, in the absence of an autopsy having been performed. While the Veteran and her representative have submitted literature obtained from the internet, including from VA websites, both physicians' rendering opinions in this case also noted that medical literature did not support a favorable opinion. As to this, the Board must consider only independent medical evidence to support the findings rather than provide a medical judgment in the guise of a Board opinion. Colvin v. Derwinski, 1 Vet. App. 171, 172 (1991). The Board thus finds that the probative value of the opinions rendered by the VA physicians in this case exceeds that of the lay opinions of the appellant and her representative, even when considered together with the literature obtained from the internet. Here, there is no medical or other competent opinion addressing the question of the cause of the Veteran's death. Given these facts, the unrebutted medical opinions which weigh against the claim must be given greater probative value than the lay statements and testimony of the appellant and the Veteran's grandson. Since for the reasons stated the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Thus, the appellant's claim for entitlement to service connection for the cause of the Veteran's death must be denied. See 38 C.F.R. § 3.312. ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs