Citation Nr: 1306482 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 06-33 018 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for rheumatoid arthritis, to include as secondary to Agent Orange exposure. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from February 1962 to March 1970. This case is before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the service connection claim for rheumatoid arthritis. In August 2010, the Board remanded the Veteran's claim for further examination. Subsequently, the case was again remanded by the Board in June 2012, at which time the Board elected to pursue additional development in conjunction with the service connection claim. A review of the file reflects that there has been substantial compliance with the actions requested in those Remands and the case has returned to the Board for appellate consideration. See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). A February 2013 review of the Virtual VA (VVA) paperless claims processing system reveals that VA/CAPRI records were associated with the VVA file in June and December 2012. The SSOC issued in December 2012 reflects consideration of those records. The claim of entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU) (previously noted in the June 2012 Board Remand) has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam; therefore, exposure to herbicides including Agent Orange is presumed. 2. Rheumatic arthritis is not among the enumerated conditions for which service connection may be established on a presumptive basis based on exposure to Agent Orange or other herbicide agents used during service in Vietnam. 3. No form of arthritis was manifested during service or during the first post-service year, and currently diagnosed rheumatic arthritis is not shown to be causally or etiologically related to service, or any incident therein. CONCLUSION OF LAW The criteria for a grant of service connection for rheumatoid arthritis have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). The RO informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claim in letters dated in October 2005 and April 2006, wherein the Veteran was advised of the provisions relating to the VCAA. The Veteran was advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to the VA. The Board further observes that the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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. The Veteran was provided with notice of the type of evidence necessary to establish a disability rating or effective date as was discussed in the Dingess case in April 2006, after the initial adjudication of the claim in January 2006. Thereafter, the RO adjudicated the claim in a Statement of the Case (SOC) issued in September 2006, and in a Supplemental SOCs issued in 2011 and 2012. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the issues on appeal has been obtained. The Veteran's service treatment records (STRs) and post-service treatment records, including private medical reports and VA records, have been obtained and associated with the file. In addition lay statements have also been added to the file along with contentions and arguments provided by the Veteran and his representative. Records from the Social Security Administration (SSA) were also sought for inclusion in the file. VA's duty to assist also includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). During the appeal period, VA examination were conducted in September 2010 and June 2012. The Veteran and his representative have not maintained that these examination were inadequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). Accordingly, the Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). Background The Veteran's DD 214 Forms show that he served in the United States Marine Corps from February 1962 to March 1970 with an MOS of auto/truck mechanic. The Veteran's awards and decorations include a Combat Action Ribbon. In July 2005, the Veteran filed an original service connection claim for arthritis in every joint of the body. A review of the service treatment records (STRs) does not reflect any complaints, treatment or a diagnosis of arthritis during service or any symptoms reasonably attributed thereto. The February 1962 enlistment examination report revealed no orthopedic or clinical abnormalities and reflected that the Veteran specifically denied having current problems or a history of rheumatism or arthritis. In March 1965, the Veteran sustained a puncture would of the skin on the upper leg. X-ray films revealed no bony pathology. A June 1969 record indicates that the Veteran hit his leg on a car door; X-ray films were negative. The March 1970 discharge examination was entirely negative for orthopedic or clinical abnormalities and failed to mention any type of arthritis. A March 1983 record from the Bond Clinic indicates that the Veteran complained of a 2-month history of diffuse joint pain. He indicated that this began as an acute onset of pain and stiffness over the metatarsal heads, as well as swelling around the feet and ankles, progressively affecting the shoulders, wrist and neck. A past history of low back strain in 1982, resulting in minimal problems was noted. Symmetrical polyarthritis, consistent with rheumatoid arthritis was diagnosed. Private medical records from the Bond Clinic dated from 1994 to 2003 reveal that the Veteran was treated for diagnoses of rheumatoid arthritis, osteoporosis, and osteoarthritis, to include of the spine (September 2002 record). A medical report of July 2001, revealed mild osteopenia of the lumbar spine and severe osteopenia of the hip, as well as osteoporosis of the neck. VA records from 2003 to 2005 reveal continued treatment for rheumatic arthritis and document symptoms affecting the hands and feet, as well as pain in the knees and hips. An entry dated in September 2003 includes a diagnosis of rheumatoid arthritis as well as a comment to the effect that there is a possibility that patient's rheumatoid arthritis may be due to Agent Orange exposure in Vietnam. On Agent Orange evaluation of January 2004, a history of rheumatoid arthritis since 1983, and osteoarthritis since 1988 were noted. It was concluded that no diseases related to Agent Orange were found at that time. A July 2005 note reflected that rheumatoid arthritis was diagnosed and that rheumatoid changes of the hands were shown bilaterally. The doctor commented that it was very possible that severe rheumatoid arthritis was due to the Veteran's time in Vietnam. In March 2006, a medical statement was issued by VA doctor. Therein, the doctor noted the Veteran's long history of rheumatoid arthritis and indicated that he had been treating the Veteran since April 2001. It was stated that the condition had progressed beyond being treatable by primary care and the doctor observed that the Veteran had previously worked as a mechanic, but that his rheumatoid arthritis now precluded the possibility of further work in that or any field. The file contains VBA Fast Letter 03-02 issued in June 2003, concerning conditions for which no presumptive service connection based on herbicide exposure will be established. A VA examination was conducted in September 2010. The history indicated that rheumatoid arthritis had its onset in 1982 or 1983, becoming progressively worse thereafter. The Veteran's complaints included: diffused body joints, spinal pain, pain in the shoulders, wrists and ankles, and progressive deformity of the hands. A diagnosis of rheumatoid arthritis of the shoulders, ankles and wrists was made. The examiner opined that there was no evidence to support that the Veteran's rheumatoid arthritis had its onset in service. It was noted that STRs, including interval physicals and the separation physicals from 1966 to 1970 were silent for hand and joint disabilities. The examiner also noted that the claims file showed that the Veteran's rheumatoid arthritis was established in the 1980's. The examiner concluded that it was less likely as not that the Veteran's rheumatoid arthritis was related to service, to include Agent Orange exposure. Additionally, the examiner noted that rheumatoid arthritis was not included on the list of presumptive medical disabilities due to Agent Orange exposure at that time. The Veteran's records from the Social Security Administration (SSA) were received in June 2012. The SSA decision accompanying those records reflects that the Veteran was determined to be disabled effective from July 2002, due to a primary diagnosis of rheumatoid arthritis. Pursuant to a June 2012 Board Remand, a VA examination was conducted in June 2012 and the claims file was reviewed. The Veteran reported to the examiner that rheumatoid arthritis was diagnosed on or about 1983. Based on the results of the examination, as well as a review of the claims file and a specific notation to the effect that the Veteran's lay statements were considered, the examiner opined that rheumatoid arthritis was less likely than not (less than 50 percent probability) incurred in or caused by any in-service disease, event, or injury, to include herbicide exposure. The following rationale was provided: "Review of currently available medical records fails to document chronicity of claimed condition during service or after discharged from service." It was noted that the Veteran was released from service in 1970, with STRs silent for rheumatoid arthritis or arthritis of the joint, and that rheumatoid arthritis was first diagnosed in 1983. Accordingly, the examiner indicated that there was no chronicity of symptomatology since service. The examiner also noted that Agent Orange exposure in service was not definitively conceded in this case. In this regard, the examiner referenced a record dated April 12, 2001 documenting a plan for an Agent Orange examination, and another note dated September 3, 2003 documenting the possibility that rheumatoid arthritis may be due to Agent Orange exposure in Vietnam. Also recorded was an Agent Orange program note dated January 6, 2004 documenting an, "Impression: no disease related to Agent Orange at this time." Also mentioned was a provider note dated July 6, 2005 stating that rheumatoid arthritis may be due to Agent Orange exposure, although no supporting evidence was documented by the provider at any time. The examiner referenced a VA examination report dated September 24, 2010 which indicated a negative opinion for service connection secondary to Agent Orange exposure. The examiner stated that a review of currently available medical literature failed to recognize rheumatoid arthritis on the list of presumptive diseases associated with exposure to Agent Orange at any time (per http://www.publichealth.va.gov/exposures/agentorange/diseases.asp). In conclusion, the examiner indicated that a review of currently available medical records failed to support any service related disease, event or injury to account for rheumatoid arthritis. Review of currently available medical literature (up-to-date) notes "Rheumatoid arthritis (RA) is a symmetric, inflammatory, peripheral polyarthritis of unknown etiology." It was noted that the Veteran had a documented diagnosis of rheumatoid arthritis by his private provider as of March 1983 and that there was no current known or documented etiology for this condition. Also obtained and associated with the claims file were the Veteran's treatment records from the following facilities: the Tampa, FL, VA Medical Center (VAMC), dated January 2010 through May 2011; the Miami, FL, VAMC, dated April 2011 through May 2011; and the Orlando, FL, VAMC, dated December 2009 through November 2012. While these records revealed continued treatment for rheumatoid arthritis, they did not discuss the etiology of this condition or in any way link it to the Veteran's military service or any incident therein. Analysis The Veteran contends that rheumatoid arthritis is linked to exposure to herbicides including Agent Orange during service, warranting service connection on that basis. Generally, in order to prevail on the issue of service connection, there must be (1) evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. See 38 C.F.R. § 3.303(b) (2012). 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." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Service connection shall be granted to a veteran if the veteran served 90 days or more during a war period or after December 31, 1946, or had peacetime service on or after January 1, 1947, and conditions including: arthritis, although not otherwise established as incurred in or aggravated by service, are manifested to a compensable degree within one year following the requisite service. 38 C.F.R. §§ 3.307, 3.309 (2012). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Under 38 C.F.R. § 3.303(b), the second and third Hickson elements may be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007). 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 v. Gober, 10 Vet. App. 488, 495-96 (1997). Additionally, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The enumerated diseases which are deemed to be associated with herbicide exposure are found under 38 C.F.R. § 3.309(e). In addition to the presumptive regulations, a claimant may establish service connection for diseases not listed as presumptive based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The file contains evidence that rheumatoid arthritis was diagnosed in 1983 and has been chronically symptomatic and continually treated thereafter; as such, Hickson element (1), evidence of current disability, has been established. With regard to Hickson element (2), in-service incurrence, review of the available STRs fails to reveal any mention of arthritis. Significantly, the Veteran's separation examination of March 1970 is on file which does not include any indication of arthritis in any area, or any abnormality of the musculoskeletal system. The Board observes that the Veteran's separation physical examination report is highly probative as to his condition at the time of his release from active duty, as it was generated with the specific purpose of ascertaining his then-physical condition, as opposed to his current assertions made many decades after the service that are being proffered in an attempt to secure VA compensation benefits. See Lilly's An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Cf. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (pecuniary interest in benefits may affect credibility of claimant's testimony). See generally Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). Private medical evidence on file reflects that at the earliest, rheumatoid arthritis was first diagnosed and treated in 1983, 13 years after the Veteran's discharge from service. As such, arthritis was not diagnosed during service or within the first post-service year. A chronic disease need not be diagnosed during the presumptive period under 38 C.F.R. § 3.307(c), but if not, there must then be shown by acceptable medical or lay evidence, characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). In this case, clinical evidence reflects that it was more than a decade after service that there was any indication of arthritis. Accordingly, service connection on a presumptive basis is not warranted. Pursuant to the above discussion, the Veteran has not specifically alleged, nor does the evidence reflect that rheumatoid arthritis was diagnosed during service or the first post-service year, or at any time prior to 1983, more than a decade after the Veteran's discharge from service. The remaining question therefore, is whether the currently claimed rheumatoid arthritis was incurred during or as a result of the Veteran's active military service, presumptively or otherwise. The Court of Appeals for the Federal Circuit has held that a Veteran seeking disability benefits must establish the existence of a disability and a connection between the Veteran's service and the disability claimed. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In this regard, he primarily maintains that rheumatoid arthritis, diagnosed years after service, is etiologically related to Agent Orange exposure sustained in service. The Board observes that in light of the Veteran's receipt of a Combat Action Ribbon, the provisions of 38 U.S.C.A. § 1154(b) are applicable in this case, which state, in pertinent part, that in any case where a Veteran is engaged in combat during active service, lay or other evidence of service incurrence of a combat related disease or injury will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence during service, and, to that end, VA shall resolve every reasonable doubt in favor of the Veteran. However, the provisions of 38 U.S.C.A. § 1154(b) do not establish a presumption of service connection but ease a combat Veteran's burden of demonstrating the occurrence of some in-service incident to which the current disability may be connected. Clyburn v. West, 12 Vet. App. 296, 303 (1999). Stated in a more specific manner, a combat Veteran's assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service. 38 U.S.C.A. § 1154(b); see also Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat Veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. As a practical matter, the provisions of 38 U.S.C.A. § 1154(b) are of little assistance in this case. With respect to service incurrence, rheumatoid arthritis was not diagnosed during service or for decades thereafter; nor does the Veteran even maintain that symptoms of rheumatoid arthritis first appeared in service. The provisions of section 1154(b) are arguably applicable in this case as to the material issue of in-service exposure to herbicides; however, such exposure is already presumed and has been established in this case, as discussed herein. In this regard, a veteran who served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307. "Service in Vietnam" includes service in the waters offshore, or service in other locations if the conditions of service involved duty or visitation in Vietnam. 38 C.F.R. § 3.313. In this case, the evidence establishes that the Veteran served in the Republic of Vietnam during the Vietnam Era. Therefore, exposure to herbicide agents during service is presumed by regulation. However, rheumatoid arthritis is not included among those disabilities for which service connection may be presumed based on exposure to herbicides. 38 C.F.R. § 3.309(e). VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically determined that a presumption of service connection is warranted. See 59 Fed. Reg. 341-46 (Jan. 4, 1994); see also 61 Fed. Reg. 57,586-57,589 (Nov. 7, 1996); see also 68 Fed. Reg. 27,630 - 27,641 (May 20, 2003); 72 Fed. Reg. 32,345 - 32,407 (June 12, 2007); 74 Fed. Reg. 21,258 - 60 (May 9, 2009). Thus, the presumptive provisions related to herbicide exposure do not provide a basis upon which to establish service connection for rheumatoid arthritis. A veteran may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). In this regard, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). In this case, the file contains four medical opinions addressing the etiology/onset of rheumatic arthritis. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The most probative evidence of record does not support a finding that the Veteran's currently diagnosed rheumatic arthritis is etiologically or causally associated with service, to include by virtue of presumptive exposure to Agent Orange/herbicides therein. In this regard, the June 2012 VA opinion was specifically sought to address the complex medical issues raised in this case and to reconcile and consider the prior evidence and opinions provided for the file. In doing so, the VA examiner reached the following conclusions: (1) rheumatoid arthritis was less likely than not (less than 50 percent probability) incurred in or caused by any in-service disease, event, or injury, to include herbicide exposure, as available medical records failed to document chronicity of claimed condition during service or after discharge from service; (2) review of currently available medical literature failed to recognize rheumatoid arthritis on the list of presumptive diseases associated with exposure to Agent Orange; and (3) review of currently available medical records failed to support any service related disease, event or injury to account for rheumatoid arthritis; observing that rheumatoid arthritis was a symmetric, inflammatory, peripheral polyarthritis of unknown etiology. As the conclusions reached by the VA examiner in 2012 were based on review of the Veteran' s lay history, to include service and post-service records and examination results, as well as on specialized clinical experience and knowledge, this evidence is considered both competent and highly probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Therefore, Board finds no adequate basis to reject this competent medical opinion based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In addition, the Veteran has not provided any competent medical evidence to rebut this opinion or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). The Board also notes that similar conclusions were made by the VA examiner in 2010, although that opinion is considered lower probative, in that the examiner failed to provide a clear opinion and supporting rationale in conjunction with that opinion. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), in which the Court held that the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and has a sound reasoning for the conclusion. In contrast, the file contains less probative medical opinions provided by VA providers in September 2003 and July 2005 to the effect that it was possible that the Veteran's rheumatoid arthritis may be due to Agent Orange exposure in Vietnam. As an initial matter, there is no indication that either of the aforementioned opinions were based on a review of the Veteran's full medical history, including STRs. Moreover, while presumptive exposure to herbicides in service is established, there is no indication in the file of the length, type, or strength of such exposure. In essence, the 2003 and 2005 opinions are based on mere speculation, unsupported by facts or evidence in the record or specific to the Veteran's case. Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). In essence, the Board observes that an award of service connection may not be based on resort to speculation or remote possibility. See 38 C.F.R. § 3.102. Hence, these opinions are of little probative value. To the extent that the Veteran assert that he suffers from rheumatic arthritis as a result of herbicide exposure sustained therein, the Board does not question the Veteran's sincerity of his belief that such an etiological relationship exists. While he is certainly competent to relate events in service and after service, such as reporting symptoms occurring post-service and in-service, there is no evidence that he possesses the requisite medical training or expertise necessary to render him competent to offer evidence on the complex medical matters in this case involving the etiology and onset of rheumatic arthritis. Cromley v. Brown, 7 Vet. App. 376, 379 (1995). Essentially, it is beyond the Veteran's competency to link his currently manifested rheumatic arthritis to service, to include herbicide exposure presumptively sustained therein. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Moreover, the Veteran does not assert, nor does the evidence establish or even suggest, chronicity or continuity of arthritic symptomatology in and since service. The fact remains that arthritis was not clinically diagnosed until 1983, nor did symptoms arise until that approximate time period. To the extent that the Veteran may have raised more general contentions to the effect that his arthritis was incurred in or is otherwise related to service. Evidence of a link between current disability and service must be sufficient and, the Board must consider lay evidence, but give it whatever weight it deems it is entitled. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that a Veteran's conclusory statements regarding causation were not sufficient to necessitate a VA examination in the absence of medical evidence, and that medical examinations are not to be routinely and automatically provided to all veterans in disability cases involving nexus issues). To the extent that the Veteran himself asserts he suffers from arthritis as a result of service, while the Veteran is generally considered competent to relate events in service and after service, and to describe the nature of his current symptomatology, there is no evidence that he possess the requisite medical training or expertise necessary to render him competent to offer evidence on matters such as medical diagnosis or medical causation. Cromley v. Brown, 7 Vet. App. 376, 379 (1995). Essentially, it is beyond the Veteran's competency to link his claimed arthritis to service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Essentially, as the weight of the evidence is against a finding that any type of arthritis was incurred in service or during the first post-service year, or is otherwise etiologically is related to service, the preponderance of the evidence is against this service connection claim. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. ORDER Entitlement to service connection for rheumatoid arthritis, to include as secondary to Agent Orange exposure, is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs