Citation Nr: 1312960 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 07-24 233 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an eye disorder. 2. Entitlement to service connection for hepatitis C. 3. Entitlement to service connection for chronic renal failure, claimed as due to exposure to herbicides. ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran served on active duty from February 1973 to February 1975. This matter is on appeal from the San Juan, Puerto Rico, Department of Veterans Affairs (VA) Regional Office (RO). This claim for renal failure was remanded by the Board in February 2009 and December 2011 for further development and is now ready for disposition. FINDINGS OF FACT 1. The Veteran did not have service in the Republic of Vietnam and exposure to herbicides is not presumed. 2. Incipient cataracts were not shown in service and are not related to any incident of service; a refractive error of the eye is not a disability for which service connection may be granted. 3. Hepatitis C was not shown in service and is not related to any incident of service. 4. Chronic renal insufficiency was not shown in service and is not related to any incident of service. CONCLUSIONS OF LAW 1. A chronic eye disorder was not incurred in or aggravated by service; a refractive error of the eye is not a disability for VA purposes. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1154(b), 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. Hepatitis C was not incurred in or aggravated by active service, and may not be presumed to have been incurred in service, to include as a result of in-service exposure to Agent Orange or any other herbicide agent. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 3. Chronic renal failure, claimed as due to herbicide exposure, was not incurred in or aggravated by service, and may not be presumed to have been incurred in service, to include as a result of in-service exposure to Agent Orange or any other herbicide agent. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103(a), 5103A, 5107(b) (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 CONCLUSIONS Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned, continuity of symptoms is required. 38 C.F.R. § 3.303(b). The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). 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 disorder and the post-service symptomatology. Clyburn v. West, 12 Vet. App. 296, 302 (1999). In this case, none of the claims on appeal are listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. The third alternative for granting service connection is that certain chronic diseases may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In this case, as above, none of the claims on appeal are listed in 38 C.F.R. §§ 3.307, 3.309(a); therefore, the one-year presumption does not apply. Finally, service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In this decision, the Board has considered the lay evidence as it pertains to the issues. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). "Competent medical evidence" means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to evaluating the medical evidence, generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. 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). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Eye Disorder The Veteran did not clarify his eye disability claim. His February 2008 claim, February 2008 notice response, November 2008 notice of disagreement, and April 2010 Form 9 are the only statements which he has submitted in support of this claim. None identify symptoms which he experiences. There is, in essence, no lay evidence regarding the nature of the eye disorder. Further, he has not alleged the onset of lay observable symptoms of cataracts during service nor has he alleged that a medical professional has told him that the cataracts began during service. The Veteran's VA treatment records contain two relevant evaluations of his eyes. A June 2006 basic eye examination found refractive error of the eye and incipient cataracts. An August 2008 optometry note diagnosed a refractive error of the eye. No other eye disorder was found. Cataracts were listed as an option in the optometry note, but the optometrist checked that the lenses were clear instead. The Veteran did not report a history of eye surgery. Although the record is in conflict as to whether the Veteran has cataracts, the Board will assume for the purposes of this decision that he does. This assumption establishes the current disability element and the first element has been met. The service treatment records are negative for any manifestations of any eye disorder. The January 1975 Report of Physical Examination found all body systems clinically normal. The accompanying Report of Medical History does not bear one positive indication on in-service symptoms. A handwritten notation at the conclusion of the form noted that the Veteran had "no current medical problems." Therefore, an eye disorder such as cataracts, or any symptoms reasonably attributed thereto, was not noted in service treatment records. The Veteran has not offered any statement alleged a particular event, injury, or disease caused his cataracts and the Board cannot discern one from the evidence of record. The preponderance of the evidence shows that he did not experience an in-service event, injury, or disease which incurred his cataracts. As the second element (in-service incurrence) is not demonstrated with respect to an eye disorder, the claim for service connection on this issue is denied. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred). Next, refractive error of the eyes is considered congenital or developmental defects, and therefore is not a disability within the meaning of applicable regulations providing for payment of VA disability compensation benefits. 38 C.F.R. §§ 3.303, 4.9. In claims for service connection for refractive errors, the law is dispositive; therefore the claim must be denied as to refractive error because of lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426 (1994). There being no other basis on which to consider the claim, the preponderance of the evidence is against the eye disorder claim. Consequently, the benefit-of-the-doubt rule does not apply, and the appeal is denied. Hepatitis C The Veteran's VA treatment records show hepatitis C originally diagnosed in April 2006. The current disability element is satisfied on this claim. The second element of service connection is an in-service event, injury or disease which either incurred or aggravated the current disability. The evidence must show that the Veteran's hepatitis C infection, risk factor(s), or symptoms were incurred in or aggravated by service. Risk factors for hepatitis C include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine use, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes or razor blades. VBA letter 211B (98-110) November 30, 1998. The Veteran was asked to provide evidence of what in-service event, injury, or disease incurred or aggravated hepatitis C, including as to the hepatitis C risk factors, in February 2008. He responded that he wanted his VA treatment records associated with the claim and that he had no other evidence to submit. His February 2008 claim, February 2008 notice response, November 2008 notice of disagreement, and April 2010 Form 9 are the only statements which he has submitted in support of this claim. None clarify the basis of the hepatitis C claim. The Veteran has offered no lay evidence regarding his hepatitis C disability, either in describing his symptoms, their onset, or incident of service to which he relates his hepatitis C. The Veteran's service treatment records do not show any hepatic disorders. He was not treated for a liver disorder during service. The January 1975 Report of Physical Examination for his separation from service found all body systems clinically normal. The accompanying Report of Medical History does not bear one positive indication on in-service symptoms. As noted above, a handwritten notation at the conclusion of the form noted that he had "no current medical problems." There are also no notations of hepatitis C risk factors in the service treatment records. The evidence does not show blood transfusions, hemodialysis, IV drug use, intranasal cocaine use, high-risk sexual activity, accidental exposure while a health care worker, or percutaneous exposure. The Veteran's VA treatment records contain a reference to one of the hepatitis C risk factors. In April 2006, the Veteran claimed that he had used IV drugs while in the Army over thirty years before. Drug abuse is the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301. Alcohol abuse and drug abuse, unless they are a secondary result of an organic disease or disability, are considered to be willful misconduct. 38 C.F.R. §§ 3.301(c)(2), 3.301(c)(3). The isolated and infrequent use of drugs by itself will not be considered willful misconduct. However, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. 38 C.F.R. § 3.301(c)(3). VA's General Counsel has confirmed that direct service connection for a disability that is a result of a claimant's own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. See VAOPGCPREC 7-99 (1999) (64 Fed. Reg. 52,375) (June 9, 1999); VAOPGCPREC 2-98 (1998) (63 Fed. Reg. 31,263) (Feb. 10, 1998). The Board finds that there is no legally permitted in-service event, injury, or disease to which the Veteran's hepatitis C may be related. The disability was not shown during service or for decades afterward. The only risk factor occurring during service was IV drug use. His claim was filed in February 2008, long after the October 1990 restriction on drug abuse and willful misconduct became law. There is no other in-service event, injury, or disease to which his hepatitis C may be related. The preponderance of the evidence is against an in-service event, injury, or disease to which the hepatitis C may be related on a legally permissible basis. Without an in-service incurrence event, injury, or disease, service connection must be denied. There being no other basis on which to consider the claim, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and the appeal is denied. Chronic Renal Insufficiency The Veteran has been diagnosed with chronic renal insufficiency and treatment began in March 2006. The current disability element is established. The Veteran has not alleged the onset of lay observable symptoms his renal disease during service and he has not alleged that a medical professional has told him that the renal disease began during service. The service treatment records are negative for any manifestations whatsoever of any renal disorder. The January 1975 Report of Physical Examination found all body systems clinically normal. The accompanying Report of Medical History does not bear one positive indication of in-service symptoms. A handwritten notation at the conclusion of the form noted that he had "no current medical problems." Therefore, chronic renal disease, or any symptoms reasonably attributed thereto, was not noted in STRs. As the second element (in-service incurrence) is not demonstrated with respect to renal disease, the claim for service connection on this issue is denied. See Kahana, 24 Vet. App. at 438 (2011). Next, the Board has considered whether the Veteran's current chronic renal disease is a chronic disability under 38 C.F.R. § 3.309(a) such that continuity of symptomatology applies. As described in 38 C.F.R. § 3.309(a), "cardiovascular-renal disease, including hypertension" applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease. However, this is not the combination of manifestations shown by the record. On the contrary, the Veteran's VA treatment records reflect that he was treated for acute renal failure in March 2006. An April 2006 echocardiogram showed tiny right kidney cysts and a right nonobstructive nephrolithiasis. An irregular shape was found and he was referred for an MRI. No lesions were found by MRI. Thereafter, he was diagnosed with chronic renal insufficiency. There is no mention of either a medical or lay history of renal disease prior to March 2006. Similarly, the Veteran has not alleged the onset of lay observable symptoms his renal disease within one year of separation from service in 1975. He has not alleged that a medical professional has told him that the renal disease began during the year after separation. There are no medical records to show manifestations of renal disease within one year of service separation. The preponderance of the evidence is against an in-service event, injury, or disease to which the chronic renal insufficiency may be related. The Board has found that the Veteran was not in fact exposed to herbicides. He offers no other account of an in-service event, injury, or disease. to which his current disability may be related. The remaining evidence shows that the disability was not shown during service or for decades afterward. Without an in-service incurrence event, injury, or disease, service connection must be denied. There being no other basis on which to consider the claim, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and the appeal is denied. With respect to all claims, the Veteran seemingly has alleged that he should be granted service connection based on being exposed to herbicides as a "Vietnam veteran." Under 38 C.F.R. § 3.307(a)(6)(iii), 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. 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 U.S.C.A. § 1116(f); 38 C.F.R. § 3.313(a). The Veteran's DD-214 indicates that he had over one year foreign service; however, the same form also indicated that that the foreign service was in Germany. The RO's request for confirmation of service in the Republic of Vietnam was returned by NPRC indicating that there was no indication in the personnel records of service in the Republic of Vietnam. His original claim, submitted in January 2006, bears both a "no" to the direct question of whether he had ever served in Vietnam, and a "yes" to the question of whether he was ever exposed to herbicides. A handwritten notation indicated he was exposed to herbicides in 1974, "Vietnam," on an "alert mission." On his April 2007 notice of disagreement, the Veteran referred to himself as a "Vietnam Veteran," though the Board observes that in no statement did he ever report where he set foot in the Republic of Vietnam or a more specific date than "1974." The Board finds that by a preponderance of the evidence, he did not have service in the Republic of Vietnam and that there is no credible evidence he was ever exposed to herbicides. Therefore, there is no presumption of an in-service incurrence element available for any of the claimed disorders. As such, the claims are denied on based on the herbicide exposure presumptive bases. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in April 2006 (renal) and February 2008 (eye, hepatitis) that fully addressed all notice elements and were sent prior to the initial RO decision in this matter. The letters informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. With respect to the Dingess requirements, in October 2007 (renal) and February 2008 (eye, hepatitis), the RO provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to all issues on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In determining whether a medical examination be provided or medical opinion obtained, there are four factors to consider: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the service treatment records and VA medical records are in the file. In addition, the Social Security Administration records have been associated with the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. Next, the Board concludes that an examination is not necessary for the refractive error of the eye claim. As discussed above, refractive error of the eye is not subject to service connection. Therefore, a medical examination would be of no consequence to resolution of the claim and one need not be ordered. Sabonis v. Brown, 6 Vet. App. 426 (1994). As to the remaining claims, the Board concludes an examination is not needed because the only evidence indicating the Veteran's current cataracts, hepatitis C, and chronic renal failure are related to service is his own lay statements that he should be granted service connection. Either competent lay or medical evidence is required to establish "an indication" that the Veteran's current disability is related to the in-service event on which the Veteran relies as the cause of his current disability. See Waters v. Shinseki, 601 F.3d 1274, 1277-78 (Fed. Cir. 2010). Here, the Veteran offers only his own conclusory opinion regarding entitlement. He does not offer any account of lay observable symptoms. The etiologies of cataracts, hepatitis C, and chronic renal failure are outside the realm of common lay knowledge. The Veteran has not provided competent lay evidence derived from personal knowledge or what he has been told by a medical professional. This is insufficient to satisfy the criteria of 38 U.S.C.A. 5103A(d)(2). As there is no competent evidence of record demonstrating in-service incurrence or some causal connection, an examination is not warranted. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded the chronic renal failure appeal twice in February 2009 and December 2011. In February 2009, the Board instructed that the Veteran's SSA records be obtained and a supplemental statement of the case (SSOC) issued. The Veteran's SSA records were obtained but an April 2012 SSOC omitted the renal failure issue. The Board remanded again in December 2011 for compliance with the instruction to issue a SSOC. A July 2012 SSOC was issued which satisfied the February 2009 and December 2011 instruction. The Board finds that the RO complied substantially with February 2009 and December 2011 remand instructions. Further remand for additional development of the prior remand instructions is not warranted. Therefore, the available records and medical evidence have been obtained in order to make adequate determinations as to these claims. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for an eye disorder is denied. Service connection for hepatitis C is denied. Service connection for chronic renal failure, claimed as due to exposure to herbicides, is denied. ______________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs