Citation Nr: 1308151 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 09-37 478 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a lung disability. 2. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance of another person or by reason of being housebound. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2012). The Veteran served on active duty from September 1964 to June 1965. This matter comes before the Board of Veterans' Appeal (Board) on appeal of a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas that denied the Veteran's request to reopen a previously-denied claim of service connection for residuals of pneumonia (claimed as asthma, lung problems, chronic obstructive pulmonary disease and emphysema) and also denied entitlement to SMC for aid and attendance/housebound. In January 2012 the Veteran and his spouse testified before the undersigned Veterans Law Judge in a hearing at the RO ("Travel Board" hearing). A transcript of the hearing is of record. In March 2012 the Board issued a decision that reopened the previously-denied claim of service connection for a lung disability and remanded the issue to the Originating Agency for further development of the merits. The Board's action also remanded the issue of entitlement to SMC, based on a determination that the two issues are inextricable intertwined. The actions required by the Board's remand have been accomplished, and the file has been returned to the Board for further appellate review. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran does not have a disorder of the lungs that was present in service or until many years thereafter and that it is not related to service or to an incident of service origin. 2. The Veteran has no service-connected disabilities. CONCLUSIONS OF LAW 1. A lung disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The criteria for SMC based on the need for the regular aid and attendance of another person or at the housebound rate are not met. 38 U.S.C.A. § 1114 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.350, 3.352 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the Veteran's claims on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Complete notification in this case, to include the disability-rating and effective date elements of a service-connection claim, was provided to the Veteran by a letter in July 2007, and the Veteran was advised of the elements required to show entitlement to SMC for aid and attendance by a letter in November 2007. The Veteran had ample opportunity to respond to both letters prior to issuance of the February 2008 rating decision on appeal. The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran's service treatment records (STRs) and service personnel records are associated with the file, as are post-service treatment records from those VA and non-VA medical providers the Veteran has identified as having potentially relevant records. Social Security Agency (SSA) disability records are also on file. The Board previously reviewed the file and determined additional medical examination and opinion should obtained, which was accomplished by an examination in July 2012 with addendum opinion in November 2012. The Board has reviewed the examination report and finds the Originating Agency substantially complied with the requirements articulated in the Board's remand instructions. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Neither the Veteran nor his representative has made the Originating Agency or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and neither has argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced the appellant in the adjudication of his appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service Connection for a Lung Disability Applicable Statutes and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). 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); see also Jandreau, id. 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 United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) 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, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. 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 v. Nicholson, 20 Vet. App. 79 (2006). 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, 22 Vet. App. at 304; 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."). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Evidence and Analysis Service treatment records (STRs) show the Veteran was treated in February 1965 for a persistent head cold that was determined to be pneumonia. He was treated with penicillin for diagnosed acute pneumonitis, cause or organism undetermined. The Veteran was discharged back to duty in March 1965 for diagnosed status post pneumonitis. The Veteran had a discharge physical examination in June 1965 in which he characterized his own overall health as "excellent" and denied history of respiratory complaints other than hay fever (he specifically denied sinusitis, asthma, shortness of breath, pain or pressure in the chest or chronic cough). The corresponding examination report showed clinical examination of the lungs and chest as "normal." A letter from Dr. Seth B. Cowan dated in October 1993 states the Veteran was being treated for bronchitis and upper respiratory infection (URI). In March 1996 Dr. William Lumly stated an impression of chronic obstructive pulmonary disease (COPD) associated with long-term cigarette abuse, history of reactive airway disease and asthmatic bronchitis and chronic rhinitis/sinusitis. Dr. Lumly noted the Veteran had a history of significant respiratory problems over the past 2-3 years and a long-term history of cigarette smoking (greater than 50 pack years). Current pulmonary function test (PFT) revealed dramatic airway obstruction. A follow-up by Dr. Lumly in April 1996 reiterated that the Veteran had a long smoking history but noted he had not smoked during the past year. However, the Veteran had worked as an exterminator and was exposed to dust and pesticides for many years; he was currently working as a bus driver. Various attempted treatment regimens had been largely unsuccessful. Dr. Lumly's impression was COPD, asthmatic bronchitis, perennial allergic rhinitis and no evidence of sinusitis. The file shows the Veteran complained to a non-VA provider in May 1996 of asthmatic bronchitis of 3-4 years. PFT was consistent with mild obstructive lung disease and also suggested the presence of restrictive lung disease. The clinician's diagnosis was chronic asthma with COPD. Thereafter the Veteran received frequent treatment by the same provider for respiratory complaints, usually characterized as COPD but occasionally including impressions of chronic bronchitis, asthma, sino-bronchial syndrome, pharyngitis, or rhinitis. A letter dated in January 1997 by Dr. Carl McKenney characterizes the Veteran as "one of the worst asthmatics I've ever seen." In January 1998 the Veteran was treated for exacerbation of COPD/asthma with current pneumonia, but two weeks later the pneumonia was noted to have been resolving/resolved. A July 1999 letter from Thad W. Houseman, a physician's assistant (PA), states the Veteran was currently undergoing treatment for chronic restrictive airway disease, otherwise known as asthma. A December 1999 prescription for medications by Dr. McKenney notes diagnosis of severe restrictive airway disease (RAD)/COPD. The Veteran had a VA examination in November 2001, performed by a physician. The examiner noted the Veteran's history of being treated in service for a cold that turned into bronchitis and then into pneumonia, requiring hospital treatment for about four weeks. The Veteran was discharged in 1965 and did not have significant lung problems until approximately 1992. The Veteran had a history of smoking from age 22 until sometime in his late 40s. The Veteran reported having had pneumonia approximately five times between discharge from service and 1985; he also reported a post-service history of recurrent colds and bronchitis. The examiner stated there was no evidence on examination of residuals of the in-service pneumonia (no signs of scarring in the pleura and the Veteran brought up very little mucous even when having bronchitis). Current PFT showed an obstructive pattern with very little bronchodilator response, which was indicative of subacute mid-level bronchitis with or without some interstitial changes in the lungs. The examiner stated in regard to residuals of the in-service pneumonia that the Veteran did not have the criteria for diagnosing asthma as a separate entity but did have a classic pattern of recurrent colds, bronchitis and asthmatic bronchitis with problems that are frequently termed "walking pneumonia" in clinical practice. The examiner's impression was status post pneumonia on active duty that responded poorly to treatment and was very likely related to gastroesophageal reflux. The Veteran had a chest X-ray by Medical Center of Mesquite in December 2001 due to complaints of respiratory abnormality. The interpreter's impression was hyperinflation of the lungs consistent with COPD but no acute disease demonstrated within the chest. The Veteran had computed tomography (CT) scan of the chest by Whitlock Radiology Associates in December 2001, performed due to complaint of chest pain. The interpreter's conclusions were scattered interstitial changes bilaterally (a nonspecific finding) and small focal nodular density suggesting need for follow-up. The Veteran was examined in December 2001 by Dr. Pedro Zavallos, an asthma specialist. The Veteran reported a history of asthma since childhood and also endorsed prior history of smoking. Examination of the lungs showed decreased breath sounds but no obvious wheezes, crackles or rubs. Dr. Zavallos' impression was long-standing history of asthma with questionable control status. The Veteran received treatment at the Community Hospital of Mesquite in June 2002 for complaint of increasing shortness of breath, with fever and chills. Physical examination showed no respiratory distress but showed fever and diminished breath sounds bilaterally. The Veteran was admitted for inpatient treatment with antibiotics; the discharge diagnosis was community-acquired multilobar pneumonia of the left lung and exacerbation of COPD. At the time of discharge the Veteran's cough and chest pain had resolved. A follow-up note by asthma specialist Dr. Nayer El-Ashram in July 2002 states the Veteran's recent left upper lobe pneumonia had resolved and the Veteran was doing well clinically. The Veteran was examined by Quality Care Medical Group in October 2004 in support of his claim for SSA disability benefits. His chief complaint was COPD with shortness of breath. The examiner noted the Veteran was on continuous oxygen. Pulmonary examination was grossly normal; chest X-ray in October 2004 showed an impression of emphysematous changes, without acute abnormality. The examiner's diagnosis in relevant part was end-stage lung disease. The Veteran's SSA disability file includes a self-reported Work History Report (undated) in which the Veteran reported a post-service work history of exterminator from 1970-1971, supervisor in an electric company from 1970-1983, convenience store from 1981-1983, and bus driver from 1987-2004. While working as an exterminator his job entailed mixing jugs of pesticide and using a hand sprayer inside houses and under houses. SSA eventually issued a decision in November 2004 that granted disability benefits for chronic pulmonary insufficiency, end stage lung disease (primary diagnosis) and obesity (secondary diagnosis), effective from July 2004. The Veteran had a VA pulmonary consult in July 2007 due to history of asthma and COPD. The Veteran endorsed having been a long-time smoker (greater than 30 pack-years) but stated he quit smoking 12 years earlier. The Veteran had been living abroad for the past 5 years, where he had been treated for respiratory symptoms. Since returning to the United States he had chronic shortness of breath but no true cough. Past medical history was significant for multiple episodes of pneumonia. Physical examination of the lungs was grossly normal; chest X-ray showed no acute infiltrates or medistinal lymphadenopathy and normal cardiac silhouette, although lung volumes were increased. The diagnosis was COPD. Dr. Carl McKenney issued a statement to the Veteran's service representative in September 2007 attesting that the Veteran was currently being treated for severe COPD, moderate hypertension and mild depression. Dr. McKenney noted the Veteran tended to get short of breath and to get bronchitis frequently. The Veteran presented to the VA pulmonary clinic in October 2007 for follow-up, reporting that his treatment regimen had resulted in very mild improvement in his exertional capacity; overall he felt about the same as before. Clinical examination of the lungs was grossly normal. The clinical impression was COPD with severe impairment. The Veteran was treated in the VA emergency room (ER) in January 2008 for nonproductive cough, shortness of breath and flu-like symptoms. The clinical impression was COPD and bronchitis. A VA mental health note dated in February 2008 states the Veteran expressed financial worries after having to quit his part-time job and also expressed extreme disappointment over the denial of his claim for service connection for respiratory problems (residuals of the in-service pneumonia); the Veteran's wife reported concern that the family did not have enough money to care for her aging mother. Similarly, in June 2008 the Veteran reported having financial problems, and in July 2008 he expressed guilt at not being able to give his adult sons more financial support. In July 2009 the Veteran reported being $6,000.00 in debt and his house in pre-foreclosure. In September 2009 the Veteran told his attending VA psychologist that he had caught pneumonia in service, which weakened his lungs and caused bronchitis and lesions on his bronchial tubes to the point where he now had to use oxygen. The Veteran had a VA examination in February 2010, performed by a physician who reviewed the claims file. The examiner noted the entry in STRs regarding treatment for bronchopneumonia in service and stated this did not appear to be a complicated pneumonia since there was no requirement for surgery or fluid drainage. After service the Veteran had bronchopneumonia and acute bronchitis on a number of occasions over the years, but had never had abscess or diagnosed bronchiectasis and had never required any complicated post-pneumonia recovery procedures. The examiner also noted the Veteran's smoking history and the post-service PFTs and other diagnostics. The examiner diagnosed COPD and asthmatic bronchitis, as well as obesity and diabetes mellitus. The examiner stated an opinion that the Veteran's current COPD and asthmatic bronchitis were not caused or aggravated by the in-service pneumonia because a single episode of non-complicated pneumonia would not cause residual lung damage. Rather, the Veteran's pulmonary function studies indicate he has an obstructive airway disorder typical of COPD and emphysema and more likely than not due to chronic long-standing cigarette smoking. Lung damage from recurrent pneumonia would be expected to show scarring in the lungs and restrictive findings on PFTs, neither of which had been demonstrated on the Veteran's tests. Thus, there is no evidence of record showing the Veteran to have susceptibility to infections in general other than exacerbation of his chronic bronchitis from acute viral respiratory illnesses, with no significant lasting aggravation or impairment. In his substantive appeal, received in December 2011, the Veteran asserted his claimed disorder could not be due to smoking, as the VA examiner had stated, because he did not start smoking until approximately four years after the in-service pneumonia. The Veteran testified before the Board in January 2012 that his respiratory condition had existed since his hospitalization for pneumonia in 1965 in service. He denied any respiratory problems prior to service. He described the circumstances of his pneumonia in service and stated the pneumonia had never resolved; he was still having shortness of breath and breathing problems in service when he returned to Texas. Since service he regularly had lung infections (bronchitis or pneumonia) every year. For the first ten years his infections were treated with shots and antibiotics; he was not hospitalized until 1998, but the Veteran's spouse testified that when she met the Veteran in 1987 he was hospitalized for seven days with pneumonia. The Veteran thereupon agreed he had been hospitalized in 1987, and prior to that incident he had been treated with shots. The Veteran then stated he began seeking treatment in the 1970s and was first diagnosed with COPD in approximately May 2002, but his wife testified he had been diagnosed with something in the 1990s. The Board remanded the case in March 2012 for additional VA examination, which was performed in July 2012. The examiner reviewed the claims file and noted diagnosis of COPD. The Veteran reported having had pneumonia in service with recurrent pneumonia thereafter. The Veteran reported onset of daily shortness of breath in the 1980s and diagnosis of COPD in 1999-2000. The Veteran endorsed history of smoking approximately half a pack of cigarettes per day from 1964 to 1990. The examiner performed a clinical examination and noted observations in detail. The examiner diagnosed current moderately severe COPD requiring constant nasal oxygen and use of inhalers. PFTs were consistent with small airway disease usually from smoking. The examiner stated that review of the claims file showed some confusion in private medical records regarding the Veteran's actual lung problems and diagnoses. The Veteran was variously diagnosed with asthma, asthmatic bronchitis, recurrent pneumonia and COPD, but these private records began in 1992, which is 28 years after the in-service pneumonia. Given the significant gap of 28 years of medical data, it is highly unlikely that the current COPD is proximately due to or caused by the in-service pneumonia. More likely, the Veteran's current COPD is related to long history of smoking coupled with 16 years as a bus driver with associated exposure to fumes on the road, and chronic bronchitis. None of these issues are related to service. Further, STRs reflect full resolution of the in-service pneumonia and in his separation examination the Veteran denied any lung of pulmonary problems. The VA examiner issued an addendum in November 2012 addressing the Veteran's contention of continuous respiratory problems since service as articulated in his testimony before the Board. The examiner stated he remained of the opinion that the Veteran's current COPD/bronchitis is not proximately due to or caused by the single episode of in-service pneumonia. The examiner stated that he fully acknowledged the Veteran's testimony of having developed chronic ongoing problems with his lungs after discharge from service, but this in no way proved the proximate cause of his pulmonary disability was the single episode of pneumonia in service. STRs clearly indicate the Veteran fully recovered from his in-service pneumonia. It is more likely than not that the Veteran's pulmonary problems developed due to some factor totally unrelated to active service. The examiner also noted the Veteran had reported subjectively that COPD was diagnosed in 1999-2000, so the actual length of time of his pulmonary disability was unclear. The examiner accordingly reiterated his prior opinion and that of the VA examiner in February 2010, to the effect that there is no service connection at all. On review of the evidence of record, the Board finds at the outset that the Veteran has shown an event in service (i.e., treatment for pneumonia) and medical evidence of a current disability consistently diagnosed as COPD and bronchitis. Accordingly, the first two elements of service connection cited by Davidson and Hickson are met. However, 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). This is the essence of the third part of the service connection analysis. The preponderance of the evidence, both lay and medical in this case, weighs against the claim. The VA examiner in November 2001 provided an ambiguous opinion, asserting there was no evidence on examination of residuals of the in-service pneumonia but also asserting the pneumonia on active duty had responded poorly to treatment and was very likely related to gastroesophageal reflux; the examiner did not clearly articulate an opinion as to whether or not the Veteran's current respiratory disorder was or was not likely related to service. Thereafter, the VA examiners in February 2010 and March 2012 articulated clear opinions that the Veteran's post-service disability was not incurred in service. The opinions of the VA examiners are not controverted by any other medical opinion of record. In that regard, the findings of a physician are medical conclusions that the Board cannot ignore or disregard. Further, review of the VA medical examinations/opinions shows the opinions fully conform to the criteria of Nieves-Rodriguez in that the examiners were fully informed of the pertinent factual premises (including the Veteran's subjective history), provided fully articulated opinions and supported their opinions by reasoned analyses. An injury during service may be verified by medical or lay witness statements; however, the presence of a current disability requires a medical diagnosis, and, where an opinion is used to link the current disability to a cause during service, a competent opinion of a medical professional is required. Caluza, 7 Vet. App. 498. Because in this case the competent and uncontroverted medical opinion of record shows the Veteran's claimed respiratory disorder is not related to service, the criteria for service connection are not met. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence of record the Board has considered the lay evidence offered by the Veteran in the form or his testimony (and that of his spouse) before the Board, his correspondence to VA and his statements to various medical providers and examiners. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). In this case, the Veteran's evidence is offered to establish continuity of symptoms since his pneumonia in service. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). Further, lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, 6 Vet. App. 465, 469. However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, id., 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"). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza, 7 Vet. App. 498. The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board may not ignore a veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits; personal interest may, however, affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board finds the Veteran's account of continuous symptoms since service is not credible because the Veteran is shown to be an inconsistent historian. Specifically in regard to pneumonia, his current account of breathing problems ever since the in-service pneumonia is contradicted by his self-reported Report of Medical History at the time of his discharge from service denying such symptoms; it is also inconsistent with the normal respiratory evaluation at discharge. The Veteran asserted repeatedly in his testimony that he had no respiratory problems prior to service, but this is inconsistent with his report to Dr. Zavallos in December 2001 that he had a history of asthma since childhood. The Veteran asserted in correspondence to the Board that he did not begin smoking until four years after service, but he informed the VA examiner than he began smoking in 1964 (during service). Finally, the VA mental health clinic notes show a clear interest in monetary benefits, which further reduces the Veteran's credibility. The Board acknowledges the testimony of the Veteran's spouse, but as she did not meet the Veteran until many years after his discharge from service she is not able to provide an eyewitness account of his visible symptoms since service. To the extent that the Veteran's lay testimony is offered to show a medical relationship between his current disorder and service, a layperson is not considered capable of opining, however sincerely, in regard to causation of a disability because he as a layperson is not competent to provide an opinion on a matter as complex as the etiology of a respiratory disorder, variously diagnosed. Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d 1372, 1376-77. Instead, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Id. In sum, the Board has found the criteria for service connection for a lung disability are not met and that the claim must accordingly be denied. Because the evidence preponderates against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. SMC for Aid and Attendance/Housebound Applicable Statutes and Regulations SMC is payable where a veteran has a service-connected disability or disabilities that render him so helpless as to be in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b)(3). A veteran will be considered to be in need of regular aid and attendance if he or she (1) is blind or so nearly blind as to have visual acuity of 5/200 or less in both eyes, contraction of visual field of vision to five degrees or less; (2) is a patient in a nursing home due to physical or mental incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.350(a). 38 C.F.R. § 3.350(c). The following criteria are used to determine whether a claimant is in need of the regular aid and attendance of another person: the inability of the claimant to dress himself or herself or to keep himself or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance which, by reason of the particular disability, cannot be done without aid; the inability of the claimant to feed himself or herself through the loss of coordination of the upper extremities or through extreme weakness; the inability to attend to the wants of nature; or, a physical or mental incapacity that requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222 (1996), the Court determined that it is not required that all of the conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist in order to establish entitlement to aid and assistance, but that at least one of the enumerated factors must be present. The Court added that the particular function the claimant is unable to perform must be considered in connection with his or her condition as a whole and that it is only necessary to establish that the claimant is in need of regular aid and attendance, not that there be a constant need. If the veteran does not qualify for increased benefits for aid and attendance, increased compensation benefits may still be payable if the veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the veteran is substantially confined as a direct result of service- connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Evidence and Analysis The statute and the implementing regulation stipulate that SMC is payable where a veteran has a service-connected disability or disabilities that render him so helpless as to be in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b)(3) (emphasis added). The Veteran in this case has no service-connected disabilities. Accordingly, the threshold element for entitlement to SMC is not shown. The question of whether the Veteran is in fact in need or regular aid and attendance of another person, or housebound, is not reached. ORDER Entitlement to service connection for a lung disability is denied. Entitlement to SMC based on the need for regular aid and attendance of another person or by reason of being housebound is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs