Citation Nr: 1315645 Decision Date: 05/13/13 Archive Date: 05/15/13 DOCKET NO. 10-47 535 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for diabetes mellitus, to include as due to Herbicides exposure, for accrued benefits purposes. 2. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, for accrued benefits purposes. 3. Entitlement to service connection for hypertension, for accrued benefits purposes. 4. Entitlement to service connection for renal insufficiency, for accrued benefits purposes. 5. Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty from May 1967 to November 1968. The appellant seeks surviving spouse benefits. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California which denied the appellant's claim of entitlement to service connection for the cause of the Veteran's death and entitlement to accrued benefits. The Board notes that at the time of his death the Veteran had claims pending for entitlement to service connection for diabetes mellitus, bilateral peripheral neuropathy, hypertension, and renal insufficiency. The RO also included the issue of entitlement to service connection for impaired hearing. However, that claim was denied in a September 2007 rating decision and the Veteran did not appeal the denial prior to his death, nor was a notice of disagreement received within one year following notification of that decision. Therefore, the September 2007 rating decision represents the final disallowance of the claim of entitlement to service connection for impaired hearing. 38 C.F.R. § 20.1103 (2012). Consequently, the issue of entitlement to impaired hearing for purposes of accrued benefits will not be addressed in this decision. FINDINGS OF FACT 1. The Veteran had claims for entitlement to service connection for diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency pending at the time of his death, and a claim for accrued benefits was received within one year after his death. 2. The preponderance of the evidence indicates that the Veteran was not diagnosed with diabetes mellitus during service or within one year of separation from service, and there is no competent medical evidence that links diabetes mellitus to the Veteran's period of active service, including exposure to Herbicides. 3. The preponderance of the evidence indicates that the Veteran was not diagnosed with peripheral neuropathy of the bilateral lower extremities during service, and there is no competent medical evidence that links peripheral neuropathy of the bilateral lower extremities to the Veteran's period of active service. 4. The preponderance of the evidence indicates that the Veteran was not diagnosed with hypertension during service or within one year of separation from service, and there is no competent medical evidence that links hypertension to the Veteran's period of active service. 5. The preponderance of the evidence indicates that the Veteran was not diagnosed with renal insufficiency during service or within one year following separation from service, and there is no competent medical evidence that links renal insufficiency to the Veteran's period of active service. 6. The Veteran died in February 2008. The immediate cause of death was probable myocardial infarction. Diabetes mellitus II, end stage renal disease, and coronary artery disease were listed as underlying causes of death. Hypertension and anemia were listed as other significant conditions contributing to death but not resulting in the underlying cause of death. 7. At the time of the Veteran's death, service connection was not in effect for any disabilities. 8. The competent evidence does not show that the Veteran's death was caused by an illness or disease incurred in or aggravated by active duty service including exposure to Herbicides. CONCLUSIONS OF LAW 1. For purposes of accrued benefits, service connection for diabetes mellitus is not warranted. 38 U.S.C.A. § 1110, 1112, 5103, 5103A, 5107, 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.1000 (2012). 2. For purposes of accrued benefits, service connection for peripheral neuropathy of the bilateral lower extremities is not warranted. 38 U.S.C.A. § 1110, 1112, 5103, 5103A, 5107, 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.1000 (2012). 3. For purposes of accrued benefits, service connection for hypertension is not warranted. 38 U.S.C.A. § 1110, 1112, 5103, 5103A, 5107, 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.1000 (2012). 4. For purposes of accrued benefits, service connection for renal insufficiency is not warranted. 38 U.S.C.A. § 1110, 1112, 5103, 5103A, 5107, 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.1000 (2012). 5. Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1110, 1310 (West 2002); 38 C.F.R. §§ 3.303, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). Certain additional notice requirements attach in the context of a claim for Dependency Indemnity and Compensation (DIC) benefits based on service connection for the cause of death. Generally, notice for a DIC case must include: (1) a statement of the conditions, if any, for which a veteran was service-connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. The content of the notice letter will depend upon the information provided in the claimant's application. Hupp v. Nicholson, 21 Vet. App. 342 (2007); 38 U.S.C.A. § 5103(a) (West 2002). The appellant was provided with that notice in a June 2010 letter. Hupp v. Nicholson, 21 Vet. App. 342 (2007). The RO sent correspondence in May 2008 and June 2010 and a rating decision in February 2009. Those documents discussed specific evidence, particular legal requirements applicable to the claims, evidence considered, pertinent laws and regulations, and reasons for the decisions. VA made all efforts to notify and to assist the appellant with evidence obtained, the evidence needed, and the responsibilities of the parties in obtaining the evidence. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The appellant has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the October 2010 statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. A VA medical opinion addressing the etiology of the Veteran's death was not obtained in this case. The Board finds that it was not necessary to obtain a medical opinion to resolve this claim, as the preponderance of the evidence is against a finding that the Veteran was exposed to herbicides in service and there is no competent medical evidence suggesting a link between the Veteran's period of service and the cause of his death. Wood v. Peake, 520 F.3d 1345 (Fed. Cir 2008); Delarosa v. Peake, 515 F.3d 1319 (Fed. Cir. 2008); 38 U.S.C.A. § 5103A(a) (West 2002). Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the appellant is required to fulfill VA's duty to assist her in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Accrued Benefits The appellant seeks to establish entitlement to accrued benefits on the basis that, prior to his death in February 2008, the Veteran had submitted sufficient evidence to VA to establish his entitlement to service connection for his claimed disorders including diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency. In addition, she asserts that he was exposed to herbicides while serving aboard an aircraft carrier during the Vietnam era which caused his claimed disorders and ultimately, contributed to his death. Benefits, to which a beneficiary was entitled at his death, based on evidence on file at the date of death or under existing ratings or decisions, known as accrued benefits, will be paid to survivors as provided by law. 38 U.S.C.A. § 5121(a) (West 2002); 38 C.F.R. § 3.1000(a) (2012). Applications for accrued benefits must be filed within one year after the date of death. 38 U.S.C.A. § 5121(c) (West 2002); 38 C.F.R. § 3.1000(c) (2012). In order for a claimant to be entitled to accrued benefits, the Veteran must have had a claim pending at the time of his death or else be entitled to them under an existing rating or decision. Jones v. West, 136 F.3d 1296 (Fed. Cir. 1998). Further, a claim for VA benefits pending on the date of death means a claim filed with VA that had not been finally adjudicated by VA on or before the date of death. 38 C.F.R. § 3.1000(d)(5) (2012). The term finally adjudicated claim means an application, formal or informal, which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is earlier. 38 C.F.R. §§ 3.160(d), 20.1103, 20.1104 (2012). Evidence in the file at date of death means evidence in VA's possession on or before the date of the beneficiary's death, even if the evidence was not physically located in the VA claims folder on or before the date of death. 38 C.F.R. § 3.1000(d)(4) (2012); Hayes v. Brown, 4 Vet. App. 353 (1993). In February 2007, the Veteran submitted a VA Form 21-526, Application for Compensation and/or Pension, in which he claimed service connection for impaired hearing, diabetes mellitus as due to herbicide exposure, bilateral neuropathy of the legs, and diabetic hypertension. In March 2007, the Veteran submitted a statement and indicated that he also wanted to claim entitlement to service connection for renal insufficiency. While the Veteran's service connection claims were being developed, and prior to adjudication of the claims, except for the denial of the claim for service connection for hearing loss, VA was informed of the Veteran's death in April 2008. On April 14, 2008, the appellant submitted a claim for any accrued benefits. As the Veteran had claims for service connection for diabetes mellitus, bilateral peripheral neuropathy of the lower extremities, hypertension, and renal insufficiency pending at the time of his death and the appellant filed a claim for accrued benefits within one year of the Veteran's death, the Board will consider the merits of the claims based on the evidence of record at the time of the Veteran's death. 38 C.F.R. § 3.1000 (2012). Entitlement to accrued benefits is determined based on evidence in the file or constructively of record at the time of his death. 38 U.S.C.A. § 5121(a) (West 2002); 38 C.F.R. § 3.1000 (2012). Aside from a duplicative letter and additional VA treatment reports, no additional evidence was added to the claims file after the Veteran's death. The VA treatment reports were constructively of record at the time of the Veteran's death. Therefore, there is no evidence associated with the claims file which may not be considered in the adjudication of the appellant's claims for accrued benefits. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, certain chronic diseases, including diabetes mellitus and hypertension, may be presumed to have been incurred during service if the disorder became manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1133 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The chronicity provisions are applicable where evidence, regardless of its date, shows that a Veteran had a chronic condition in service, or during an applicable presumptive period, and still has that disability. That evidence must be medical unless it relates to a condition as to which lay observation is competent. 38 C.F.R. § 3.303(b) (2012). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Although the Veteran served during a period of war, he does not allege that any of the current disabilities at issue began in combat, and therefore the provisions pertaining to proof of service incurrence or aggravation of a disease or injury in the case of a Veteran who engaged in combat with the enemy is not applicable. 38 U.S.C.A. § 1154(b) (West 2002). If a Veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116 and 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 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e) (2012). A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, 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 the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii) (2012). The presumptive diseases for exposure to herbicides include chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. Ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis, such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309(e) (2012). A Veteran must have set foot within the land borders of Vietnam for presumptive service connection and a Veteran who never went ashore from the ship on which he served only in the Vietnam coastal waters is not entitled to presumptive service connection. Haas v. Nicholson, 20 Vet. App. 257 (2006). Even where the criteria for service connection under the provisions of 38 C.F.R. § 3.309(e) are not met, a Veteran is not precluded from establishing entitlement to service connection by proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran, prior to his death, submitted a statement dated in July 2007 which indicates that he served on the USS Henry W. Tucker and was stationed 200 yards off the shore of the Republic of Vietnam in support of Marines serving in the demilitarized zone. The Veteran's service separation document shows that the Veteran had eleven months and five days of foreign and/or sea service during his period of active duty service. He received the National Defense Service Medal and his last duty assignment was on the USS Kretchmer. A response from the National Personnel Records Center (NPRC) received in March 2007 indicates that it was unable to determine whether the Veteran served in-country in the Republic of Vietnam. The response indicated that the USS Henry W. Tucker was in the official waters of the Republic of Vietnam from August 14, 1968, to September 13, 1968. The Veteran's service medical records do not show any complaints, findings, or treatment for diabetes mellitus, peripheral neuropathy of the lower extremities, hypertension, or renal insufficiency. The Veteran's blood pressure was recorded as 134/80 at his April 1966 enlistment examination, 150/88 at an annual examination in April 1967, and 130/86 at his separation examination in November 1968. His blood pressure was also recorded to be 130/90 at an annual examination in August 1970. The Veteran denied high or low blood pressure and cramps in his legs on report of medical history forms prepared in conjunction with the examination dated in April 1966 and August 1970. He reported high or low blood pressure on a report of medical history form prepared in conjunction with the April 1967 annual examination. Post-service treatment reports from VA dated from February 2007 to July 2007 show that in February 2007, the Veteran was noted to have a history of type II diabetes mellitus diagnosed in 1990, complicated by peripheral neuropathy, hypertension, and diabetic nephropathy. In July 2007, he was noted to have hypertension, chronic kidney disease, and diabetes mellitus. Associated with the claims file is a letter from J. Baranski, M.D., of Balboa Nephrology Medical Group dated in March 2007. Dr. Baranski indicated that the Veteran had been under his care since December 2005 for diabetes and associated chronic renal failure and hypertension. Dr. Baranski reported that the Veteran had progressive renal insufficiency and was preparing to begin dialysis. Dr. Baranski noted that the Veteran's renal insufficiency resulted from diabetes because the Veteran had nephrotic-range proteinuria. Dr. Baranski indicated that the Veteran's diabetes mellitus was a service-connected illness and the cause of the Veteran's renal insufficiency and hypertension. Treatment records from Balboa Nephrology Medical Group dated from August 2005 to March 2007 show that the Veteran was diagnosed with renal disease in August 2005. In March 2007, the Veteran underwent a laparoscopy for placement of a peritoneal dialysis catheter because the Veteran was noted to soon require hemodialysis. Private treatment reports from San Diego Retina are unrelated to the claims for accrued benefits issues on appeal. Associated with the claims file is a letter from W. Scheppach, M.D., received in July 2007 which states that the Veteran was his patient and reported exposure to herbicides while serving in the Navy. Private treatment records from Dr. Scheppach dated from February 1982 to October 2005 show that in February 1982, the Veteran was seen for a report of borderline high blood pressure, reported since 1968. The records thereafter show treatment for elevated blood pressure through October 2002. He was noted to have hypertension at a visit in January 2005. The Veteran was also noted to have a diagnosis of diabetes mellitus as early as April 1998. The appellant claims that she is entitled to accrued benefits for the Veteran's claimed diabetes mellitus, peripheral neuropathy of the lower extremities, hypertension, and renal insufficiency because he served in the waters off Vietnam and was exposed to herbicides while serving aboard the USS Henry W. Tucker. Further, she claims that all of his health ailments resulted from his exposure to herbicides while serving in the Navy. In considering the evidence of record and the applicable laws and regulations, the Board concludes that the appellant is not entitled to accrued benefits for the claims of service connection for diabetes mellitus, including as due to exposure to herbicides, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency. As an initial matter, the Board notes that the Veteran's period of active service did not include service in country in Vietnam during the period in which exposure to herbicides is presumed. The Veteran's service personnel records show service aboard several naval vessels during the period in which exposure to herbicides is presumed. A response from the NPRC indicates that the ship upon which the Veteran served was in the waters of Vietnam. The Veteran has not maintained that he served on land in Vietnam and the record does not substantiate such a finding. The Veteran reported that he served offshore. Therefore, the Veteran is considered to not have served in the Republic of Vietnam during the period for which the presumption of exposure to herbicides attaches. There are no findings in the record that suggest service in Vietnam, to include duty on inland waterways. In light of the requirement that a Veteran must have been physically present on the landmass or inland waters of the Republic of Vietnam at some point during his service in order to establish qualifying service in Vietnam, the Board finds that presumptive service connection based on exposure to herbicides is not warranted. Haas v. Peake, 525 F.3d 1168 (2008). The Board has also determined that accrued benefits for service connection for diabetes mellitus, peripheral neuropathy of the lower extremities, hypertension, and renal insufficiency is not warranted on a direct basis. The Board finds that the competent evidence does not show a relationship between the Veteran's diabetes mellitus, peripheral neuropathy of the lower extremities, hypertension, or renal insufficiency and his period of active service. The VA treatment records show that diabetes was diagnosed in 1990, more than 20 years after the Veteran left service. Although elevated blood pressure reading were recorded after service as early as 1982, the first medical evidence of a diagnosis of hypertension was dated in January 2005 by Dr. Scheppach, more than thirty years after the Veteran left service. Diabetic peripheral neuropathy was included as a diagnosis by VA in February 2007, more than thirty years after the Veteran left service. Finally, renal insufficiency was diagnosed by Balboa Nephrology Medical Group in August 2005, more than thirty years after the Veteran left service. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after active service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The amount of time that passed between service and the first indication of a diagnosis and treatment for the claimed diabetes mellitus, peripheral neuropathy of the lower extremities, hypertension, and renal insufficiency is evidence that weighs against the Veteran's claims. The evidence of record at the time of the Veteran's death does not show a relationship between the Veteran's diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency and his period of active service. Although Dr. Baranski indicated that the Veteran's diabetes mellitus is a service-connected illness, he provided no basis for that conclusion. Dr. Scheppach merely indicated that the Veteran reported exposure to Herbicides while serving in the Navy. However, the Board finds that exposure to Herbicides has not been established. There is no competent evidence which provides a basis for the conclusion that the Veteran's diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency are related to his period of service or that diabetes mellitus, renal insufficiency, or hypertension manifested within one year of the Veteran's separation from service. 38 C.F.R. §§ 3.307, 3.309 (2012). Although the appellant contends that the Veteran's claimed diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency are related to his active service, specifically to exposure to herbicides in service with regard to diabetes mellitus, she has submitted no competent medical evidence or opinion to corroborate that contention. 38 C.F.R. § 3.159(a)(1) (2012) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The appellant's opinion is not competent to provide the requisite etiology of the claimed disorders because that matter requires medical expertise. 38 C.F.R. § 3.159(a)(1) (2012); Duenas v. Principi, 18 Vet. App. 512 (2004); Bostain v. West, 11 Vet. App. 124 (1998); Stadin v. Brown, 8 Vet. App. 280 (1995). Therefore, her statements and those of the Veteran regarding the Veteran's diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency being related to the Veteran's service are not competent as she and the Veteran are not medically qualified to provide evidence regarding a matter requiring medical expertise, such as an opinion as to etiology. The Board finds that the preponderance of the competent evidence is against a finding that the Veteran had diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency during service and the file does not contain competent evidence linking any of the claimed disorders to service, including exposure to herbicides. In addition, diabetes mellitus, renal insufficiency, and hypertension are not shown to have manifested to a compensable degree within one year following separation from service. Accordingly, the Board finds that the preponderance of the evidence is against the claims for service connection for diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, and renal insufficiency, for accrued benefits purposes, and the claims must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). Cause of Death The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, certain chronic diseases may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). If a Veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 U.S.C.A. § 1116 and 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 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e) (2012). A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, 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 the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii) (2012). The presumptive diseases for exposure to herbicides include chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. Ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis, such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309(e) (2012). VA regulations require that a Veteran have set foot within the land borders of Vietnam for presumptive service connection and that a Veteran who never went ashore from the ship on which he served only in the Vietnam coastal waters is not entitled to presumptive service connection. Haas v. Nicholson, 20 Vet. App. 257 (2006). A surviving spouse of a qualifying veteran who died of a service-connected disability is entitled to receive Dependency and Indemnity Compensation benefits. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312 (2012). 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 either the principal or contributory cause of death. To constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b) (2012). To be a contributory cause of death, the evidence must show that the service-connected disability contributed substantially or materially to the cause of death, or that there was a causal relationship between the service-connected disability and the veteran's death. 38 C.F.R. § 3.312(c) (2012). To be a contributory cause of death, the service-connected disability must be shown to have combined with the principal cause of death, that it aided or lent assistance to the cause of death. It is not sufficient to show that it casually shared in producing death. A causal relationship must be shown. 38 C.F.R. § 3.312 (2012). Service-connected disabilities affecting vital organs should receive careful consideration as a contributory cause of death. That requires a determination as to whether there were debilitating effects and a general impairment of health caused by the service-connected disability which rendered the veteran less capable of resisting the effects of an unrelated disability. 38 C.F.R. § 3.312 (c)(3) (2012). In cases where the primary cause of death is by its very nature so overwhelming that eventual death is anticipated irrespective of coexisting disabilities, there must be a determination as to whether there is a reasonable basis that a service-connected disability had a material effect in causing death. In that situation, it would not generally be reasonable to hold that a service-connected condition accelerated death unless the condition affected a vital organ and was itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4) (2012). The appellant contends that the Veteran was exposed to Herbicides during service and that the claimed exposure caused his health to deteriorate and ultimately caused his death. At the time of the Veteran's death service connection was not in effect for any disabilities. The Veteran died in February 2008. The Veteran's certificate of death indicates that the immediate cause of death was probable myocardial infarction. Diabetes mellitus II, end stage renal disease, and coronary artery disease were listed as underlying causes of death. Hypertension and anemia were noted to be other significant conditions contributing to death but not resulting in the underlying cause of death. The Veteran's service medical records do not show any complaints, findings or treatment for diabetes mellitus, peripheral neuropathy of the bilateral lower extremities, hypertension, or renal insufficiency, nor do they show any complaints of coronary artery disease or anemia. The Veteran denied high or low blood pressure and cramps in his legs on report of medical history forms prepared in conjunction with the examination dated in April 1966 and August 1970 and he reported high or low blood pressure on a report of medical history form prepared in conjunction with an April 1967 annual examination. Post-service treatment reports from VA and private providers establish that the Veteran sought care for diabetes mellitus, peripheral neuropathy, hypertension, and renal insufficiency many years following service. None of the medical evidence includes any opinion linking any of the Veteran's causes of death to his service. While Dr. Baranski indicated that diabetes was a service-connected condition in his March 2007 letter, service-connection was not in effect for diabetes mellitus at the time of the Veteran's death. Furthermore, no rationale was offered for that opinion. The Board concludes that the greater weight of probative medical evidence weighs against a finding that the Veteran's cause of death was caused by or related to his active duty service including exposure to Herbicides. While the Veteran reported exposure to herbicides while serving aboard the USS Henry W. Tucker, a response from the NPRC indicates that the ship upon which the Veteran served was in the waters of Vietnam. During his lifetime, the Veteran did not maintain that he served on land in Vietnam and the record does not substantiate such a finding. The Veteran is alleged only to have served in the water offshore of Vietnam. Therefore, the Veteran is considered to not have served in the Republic of Vietnam during the period for which the presumption of exposure to herbicides attaches. There are no findings in the record that suggest service in Vietnam, to include duty on inland waterways and therefore exposure to Herbicides has not been established. Moreover, the Board finds that the appellant's opinion is insufficient to provide the requisite etiology of the cause of the Veteran's death because such matters require medical expertise. 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512 (2004); Stadin v. Brown, 8 Vet. App. 280 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the appellant's statements regarding the Veteran's cause of death being related to his active service, including exposure to Herbicides, are merely speculation as she is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to etiology. The significant evidentiary gap between the Veteran's active service and the first diagnosis of any of the disabilities that caused or contributed to his death, weighs heavily against the appellant's claim for service connection for cause of the Veteran's death on a direct basis. A lengthy period without treatment also is evidence that weighs heavily against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). There is also no medical evidence establishing a possible relationship between any disorder that has been found to have caused or contributed to cause the Veteran's death and the Veteran's period of active service. Other than the appellant's lay assertions that the cause of the Veteran's death was related to his service, the record is devoid of competent evidence indicating a link between the cause of the Veteran's death and any event, or incident, of the Veteran's service. A mere recitation of relationship to service by a physician, without any comment regarding rationale, is insufficient. Furthermore, where a physician attributed the cause of death of herbicide exposure, but the Board finds that herbicide exposure is not shown, that is also insufficient. The Board is very sympathetic to the appellant for the loss of her husband. Unfortunately, the Board must conclude that the preponderance of the evidence is against the appellant's claim, and service connection for the cause of the Veteran's death must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3 (2012). ORDER Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure, for accrued benefits purposes is denied. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, for accrued benefits purposes is denied. Entitlement to service connection for hypertension, for accrued benefits purposes is denied. Entitlement to service connection for renal insufficiency, for accrued benefits purposes is denied. Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs