Citation Nr: 1314218 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 08-11 111 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from July 1950 to November 1953. He was awarded the Purple Heart due to injuries sustained during combat operations. He died in April 2005. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. Due to the location of the appellant's residence, jurisdiction of this appeal is with the RO in Atlanta, Georgia. In November 2010, the appellant testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. In May 2011, the case was remanded to obtain additional treatment records and a VA medical opinion. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The appellant has submitted new evidence in the form of a medical nexus opinion, which relates to the issue on appeal. The appellant specifically waived her right to have the RO consider this evidence in the first instance. 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. The Veteran died in April 2005 as result of congestive heart failure due to or as a consequence of coronary artery disease and diabetes. 2. At the time of the Veteran's death, service connection had been established for posttraumatic stress disorder (PTSD) with major depressive disorder, evaluated as 70 percent disabling; recurrent neurodermatitis of the hands, elbows and right ankle, evaluated as 30 percent disabling; shell fragment wound scar of the forehead, evaluated as 10 percent disabling; and residual scar of the middle finger of the right hand, evaluated as noncompensably disabling. 3. The Veteran's PTSD with major depressive disorder contributed substantially or materially to the production of death. CONCLUSION OF LAW PTSD with major depressive disorder contributed substantially or materially to the cause of the Veteran's death. 38 U.S.C.A. §§ 1310, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.101, 3.159, 3.312 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the 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 and 3.326(a)(2012). In this case, the Board is granting in full the issue of service connection for the cause of the Veteran's death. Consequently, the Board finds that any lack of notice and/or development, which may have existed under the VCAA, cannot be considered prejudicial to the appellant, and remand for such notice and/or development would be an unnecessary use of VA time and resources. II. Analysis The appellant contends that the Veteran's PTSD with major depressive disorder contributed to his heart disease, which contributed to his death. See, e.g., May 2006 notice of disagreement. In order to establish service connection for the cause of the Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312(a) (2012). This question will be resolved by the use of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the Veteran, including, particularly, autopsy reports. Id. For a service-connected disability to be considered the principal or primary cause of death, it must singly, or with some other condition, be the immediate or underlying cause, or be etiologically related thereto. 38 C.F.R. § 3.312(b) (2012). In determining whether a service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1) (2012). The standards and criteria for determining whether or not a disability from which a veteran has died is service-connected are the same standards and criteria employed for determining whether a disability is service connected generally, i.e., while the veteran is still alive. 38 U.S.C.A. § 1310 (West 2002). Issues involved in a claim for DIC are decided without regard to any prior disposition of those issues during the veteran's lifetime. 38 C.F.R. § 20.1106 (2012). Based on a review of the evidence, the Board concludes that service connection for the cause of the Veteran's death is warranted. The pertinent medical evidence of record establishes that the Veteran's service-connected PTSD with major depressive disorder at least as likely as not contributed substantially to the coronary heart condition that led to the Veteran's death. In this case, at the time of the Veteran's death, service connection had been established for PTSD with major depressive disorder, evaluated as 70 percent disabling; recurrent neurodermatitis of the hands, elbows and feet, evaluated as 30 percent disabling; shell fragment wound scar of the forehead, evaluated as 10 percent disabling; and residual scar of the middle finger of the right hand, evaluated as noncompensably disabling. The Veteran's PTSD was opined to be severe. See, e.g., December 2002 VA treatment record. His records also show that he experienced symptoms of PTSD such as combat-related nightmares and insomnia since the 1950s. See March 2002 VA treatment record. The Veteran died in April 2005. The death certificate indicates that he died from congestive heart failure due to or as a consequence of coronary artery disease and diabetes. Post-service records indicate that the Veteran had coronary artery disease at least as early as February 2002 and was diagnosed with congestive heart failure in 2003. A letter from the Veteran's VA physician dated in July 2005 indicates the Veteran had symptoms from PTSD that went untreated until 2002. It was certainly possible that poor eating habits resulting from untreated PTSD had a hand in creating conditions that ultimate led to his death. The appellant reported that the Veteran over ate when he felt depressed. Poor eating habits and morbid obesity led to diabetes and hypertension, which together contributed to coronary artery disease and the cardiac ischemia that caused his heart failure. A medical opinion from F.H., M.D. also dated in July 2005 shows that they concurred with the VA physician's opinion. A VA medical opinion in October 2005 indicates that PTSD did not cause the Veteran's diabetes, coronary artery disease and congestive heart failure. However, this opinion did not indicate whether the Veteran's PTSD contributed substantially or materially, combined to cause, or aided or lent assistance to the production of death. A new medical opinion as to the issue of whether the Veteran's PTSD contributed substantially or materially, combined to cause, or aided or lent assistance to the production of death was obtained in July 2011. After reviewing the evidence of record, the examiner opined that it was at least as likely as not that the Veteran's service-connected PTSD contributed substantially to the coronary heart condition (ischemic dilated cardiomyopathy) that led to the Veteran's death. According to medical records, the Veteran had been service-connected for PTSD since 2002; however, he reported significant symptoms such as combat-related nightmares and insomnia starting as early as the 1950s. Thus, at the time of this death, the Veteran had experienced chronic symptoms of PTSD for fifty years or more. Recent studies indicate that there was a strong relationship between PTSD and coronary heart conditions, particularly in veterans. However, the exact underlying cause of the relationship between PTSD and heart conditions was unknown. The examiner referred to the July 2005 VA physician's letter. The examiner concluded that the Veteran's death was not directly caused by his service-connected PTSD, but PTSD was at least as likely as not a substantial contributor to the coronary heart condition (ischemic dilated cardiomyopathy) that ultimately led to the Veteran's death. In this case, this opinion clearly establishes that the Veteran's PTSD contributed substantially to the cause of the Veteran's death. The examiner's opinion was predicated upon a review of the Veteran's records as well as medical studies. Furthermore, a private medical opinion dated in July 2012 submitted by the appellant supports the conclusion that the Veteran's PTSD contributed substantially to his heart disease, which caused his congestive heart failure and ultimate death. After reviewing the pertinent evidence, as well as medical studies, the private examiner concluded that there was a nexus between the Veteran's service-connected PTSD and his diagnosis of cardiac disease. As for the issue of whether the Veteran's PTSD contributed to his heart condition, the opinions of the July 2011 VA examiner and July 2012 private examiner are both uncontradicted. As these opinions took into account the Veteran's pertinent medical history, as well as medical studies showing a relationship between PTSD and heart conditions, the Board accords both opinions great probative value. As such, the evidence shows that the Veteran's PTSD contributed substantially to his death. Therefore, in considering the severity of the Veteran's PTSD, the positive July 2011 and July 2012 nexus opinions, as well as the pertinent medical evidence of record, and in affording the appellant the benefit-of-the-doubt, the Board finds that it is at least as likely as not that the Veteran's PTSD contributed substantially to the cause of his death. The evidence is in favor of the grant of service connection for the cause of the Veteran's death. Service connection for the cause of the Veteran's death is granted. 38 U.S.C.A §5107 (West 2002 & Supp. 2012). ORDER Entitlement to service connection for the cause of the Veteran's death is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs