Citation Nr: 1319347 Decision Date: 06/14/13 Archive Date: 06/21/13 DOCKET NO. 09-42 278A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for a left ankle disability. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a heart disability, claimed as secondary to hypertension. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from October 1981 to April 1992. This matter comes before the Board of Veterans' Appeals (hereinafter "Board") on appeal from a January 2009 rating decision from the Department of Veterans Affairs (hereinafter "VA") Regional Office (hereinafter "RO") in St. Petersburg, Florida. The Veteran provided testimony at an April 2013 hearing before the undersigned Veterans Law Judge (hereinafter "VLJ"). A transcript of the hearing is associated with the eFolder on Virtual VA (hereinafter "Virtual VA"). In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed Virtual VA to ensure a complete assessment of the evidence. No additional documents pertinent to the present appeal were revealed. In his hearing testimony, the Veteran appears to be raising an issue of service connection for a left foot disability, which had been previously adjudicated in a final rating decision by the Agency of Original Jurisdiction (hereinafter "AOJ"). In this regard, the Veteran repeatedly referenced his left foot symptoms as being attributable to an inservice injury. The RO has not addressed this matter. As it appears the Veteran is requesting to reopen his previously denied claim of service connection for a left foot disability, this matter is referred to the AOJ for appropriate action. The claim of entitlement to service connection for a heart disorder, claimed as secondary to hypertension, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (hereinafter "AMC"), in Washington, DC. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the request to reopen the previously denied claim for service connection for a left ankle disability and the claim for service connection for hypertension have been accomplished. 2. The Veteran's original claim of service connection a left ankle disability was denied by an unappealed rating decision in April 2000, of which the Veteran was advised in April 2000. 3. The evidence received since the April 2000 rating decision is cumulative and redundant of evidence of record at the time of the prior denial, does not, when considered with previous evidence of record, relate to unestablished facts necessary to substantiate the claim, or otherwise raise a reasonable possibility of substantiating the claim of service connection for a left ankle disability. 4. The currently demonstrated hypertension is shown as likely as not to have had its onset during the Veteran's active service. CONCLUSIONS OF LAW 1. The unappealed April 2000 rating decision, which denied the claim for entitlement to service connection for a left ankle disability, is final. 38 U.S.C.A. § 7105(b), (c) (West 2002); 38 C.F.R. §§ 3.158, 3.160(d), 20.201, 20.302, 20.1103 (2012). 2. New and material evidence has not been presented since the April 2000 rating decision denying service connection for a left ankle disability; thus, the claim is not reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156(a), (c) (2012). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code (hereinafter "38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations (hereinafter "38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (hereinafter "Federal Circuit") (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (hereinafter "Court") (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issues under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. A Veteran bears the "'evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (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"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has 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). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). However, until the Veteran meets the threshold burden of submitting new and material evidence sufficient to reopen his claim, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Duties to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (hereinafter "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). 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the 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. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In claims to reopen, VA must both notify a claimant of the evidence and information necessary to reopen the claim, as well as the evidence and information required to establish entitlement to the underlying claim for the benefit that is being sought. To satisfy the above requirement, the Secretary must consider the bases for the denial in the prior decision and provide the claimant with a notice letter describing what evidence would be necessary to substantiate those elements required to establish service connection that were previously found insufficient. Kent v. Nicholson, 20 Vet. App. 1 (2006). Here, the Veteran was sent pre- and post-adjudication letters in January 2008, May 2008, August 2008 and February 2009 that provided information as to what evidence was required to substantiate the claims, including that which is required by Kent, and of the division of responsibilities between VA and a claimant in developing an appeal. The January 2008 and May 2008 letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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). The claims file contains the Veteran's service treatment records, as well as post-service private treatment records and VA examination reports. Moreover, his statements in support of the claims are of record, including testimony provided at a hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence pertinent to the Veteran's claims. Also, the Veteran was afforded VA examinations in January 2009, April 2011 and June 2012, to address the medical issues raised by the case. The Board finds that the VA examinations are generally adequate to decide the case because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they describe the claimed hypertension and left ankle disabilities in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). As the Board is not reopening the claim for the left ankle disability, any argument that the April 2011 VA joints examination is inadequate is inapposite. VA is not required to provide a new medical examination to a veteran seeking to reopen a previously and finally disallowed claim unless new and material has been presented. Woehlaert v. Nicholson, 21 Vet. App. 456, 463 (2007); cf. Shade v. Shinseki, 24 Vet. App. 110, 121 (2010) (finding a standard that would require reopening if the newly submitted evidence along with the other evidence of record, combined with VA assistance raises a reasonable possibility of substantiating the claim). The Veteran in this case is not entitled to a VA examination as new and material evidence was not submitted and, as discussed further below, does not raise a reasonable possibility of substantiating the claim of entitlement to service connection for a left ankle disability even with VA's assistance. Shade, 24 Vet. App. at 116-18. The Board accordingly finds no reason to remand for further examination. At the April 2013 hearing, the undersigned VLJ and representative for the Veteran outlined the issues on appeal and engaged in a colloquy as to substantiation of the claim, including identifying relevant types of evidence. Overall, the hearing was legally sufficient and the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); Bryant v. Shinseki, 23 Vet. App. 488 (2010). For the above reasons, no further notice or assistance to the Veteran 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). The Veteran has not made the RO, the AMC or the Board aware of any additional evidence that must be obtained in order to fairly decide the claims on appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of these issues have been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). New and Material Evidence- Left Ankle Disability The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). The preliminary question in this appeal concerns whether the claim of service connection for a left ankle disability should be reopened and adjudicated on the merits. Without the submission of new and material evidence, the Board does not have jurisdiction to review the merits of a claim, and the analysis must end. See Elkins v. West, 12 Vet. App. 209, 218-19 (1999); Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As discussed hereinbelow, the Board finds that new and material evidence has not been received. In a February 2000 rating decision, the RO denied entitlement to service connection for a left foot and left ankle disability on the basis that the Veteran failed to provide evidence of a well-grounded claim for service connection. That is, the RO determined that the Veteran failed to provide evidence of a current disability, evidence of incurrence or aggravation of a disease or injury in service, and evidence of a nexus, or link, between the in-service injury or disease and the current disability. The Veteran filed a notice of disagreement (hereinafter "NOD") with this decision, and identified outstanding service treatment records that had not been associated with the claims file at the time of the February 2000 rating decision. In a subsequent unappealed rating decision in April 2000, the RO had an opportunity to review the Veteran's service treatment records, and continued to deny entitlement to service connection for a left ankle disability. The RO based this determination on a finding that the service treatment records were negative for complaints, treatment or diagnoses referable to a left ankle or left foot disability; and cited to reports from the Veteran's private physician "Dr. Krueger," which showed he was first treated in October 1994 for left foot and ankle pain of 3 months duration and that the associated diagnosis was talocalcaneal tendinitis. There was no evidence of a link between current left ankle disability and service. The April 2000 rating decision is final but may be reopened upon receipt of new and material evidence. See 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. §§ 20.1100, 20.1103 (2012). The Veteran sought to reopen his claim in January 2008. He asserted that he currently had a left ankle disability as a result of an injury sustained in service during basic training in November 1981. He contended that his chronic left ankle problems continued throughout his 10 years of active service, and he and his spouse testified that the symptoms continued after service to the present. The Veteran's current claim to reopen service connection for a left ankle disability is based on the same factual basis that was of record when the previous claim was last decided on the merits. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); Velez v. Shinseki, 23Vet. App. 199, 203-04 (2009). Thus, new and material evidence is necessary to reopen the claim. Despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is furnished with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). However, the issue of reopening must be confined to the subject of the existence of new and material evidence alone and does not include a separate outcome-based element. See Shade, 24 Vet. App. at 121. At the time of the April 2000 denial, the pertinent evidence of record included the Veteran's service treatment records, private treatment records from "Dr. Krueger," "Dr. Saiter" and "Dr. Tappan," along with the Veteran's written statements. To reopen and review a claim that has been previously denied, new and material evidence must be submitted by or on behalf of a claimant. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). "[T]he question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied." Kent v. Nicholson, 20 Vet. App. 1, 10 (2006); see Bostain v. West, 11 Vet. App. 124, 127 (1998) (noting that the "last final disallowance" of a claim was the denial of a request to reopen). Regarding petitions to reopen filed on or after August 29, 2001, such as this one, the provisions of 38 C.F.R. § 3.156(a) define "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. See 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim(s) sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). "[T]he phrase 'raise a reasonable possibility of substantiating the claim' does not create a third element for new and material evidence." Rather, it is simply "a component of the question of what is new and material evidence," and should be informed by the question of whether the "evidence could, if the claim were reopened, reasonably result in substantiation of the claim." Shade, 24 Vet. App. 110, 117-18 (2010). New and material evidence is not required "as to each previously unproven element of a claim." Shade, 24 Vet. App. at 120. Moreover, the provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). For purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). Finally, the question of whether to reopen a claim should be considered under the standard of 38 C.F.R. § 3.159(c)(4)(iii), consistent with McLendon v. Nicholson, 20 Vet. App. 79 (2006), for determining whether a VA examination is necessary. If the McLendon standard is met, the claim should be reopened. See Shade, 24 Vet. App. 110. Evidence submitted since the April 2000 rating decision, includes written statements and hearing testimony from the Veteran and his spouse, private treatment records from "Joseph E. Kiefer," a podiatrist, and a VA joints examination report. The private treatment records from Dr. Kiefer, the Veteran's podiatrist, indicate treatment for left foot problems, such as posterior tibial tendonitis left, but do not show evidence of left ankle problems beyond findings of subtalar joint degenerative changes with peroneal spastic flat foot, tenosynovitis of the left ankle joint, and tenosynovitis, peroneal, which was representative of symptoms of swelling, tenderness, erythema and pain in the left ankle. These findings are not new but essentially duplicative of private treatment findings which were before the RO in April 2000 which showed treatment for inflammation, pain and swelling in the left ankle. This evidence does not constitute new and material evidence to reopen the claim. Moreover, the Veteran and his spouse have presented various written statements and hearing testimony in support of his claim, which have included a description of the development of his left ankle disability, and associated symptomatology. The testimony is to the effect that the Veteran does in fact have current disability of the left ankle which is related to service, and these assertions are no different from the claims he made in conjunction with his initial claim of service connection and does not constitute new and material evidence. At no time since the April 2000 rating decision has the Veteran submitted evidence suggesting that a current left ankle disability is related to service, and such evidence would serve to reopen the claim. In fact, the newly received April 2011 VA joints examination establishes that the Veteran does not have a current diagnosis of a current left ankle disability. Because this conclusion affirmatively shows that the Veteran is not diagnosed with a left ankle disability, the April 2011 VA examination does not raise a reasonable possibility of substantiating the claim. See Shade, 24 Vet. App. at 117-18. In sum, evidence does not reflect a link establishing that the claimed left ankle disability is related to injury sustained in service, which is the basis for the RO's April 2000 decision denying the Veteran's petition to reopen the claim. Although the Veteran in this case submitted new evidence, it is not material in that it did not address the only element upon which his claim previously had been denied, that of nexus. Therefore, the evidence received since the April 2000 RO rating decision does not relate to an unestablished fact necessary to substantiate the claim of service connection for a left ankle disability. Accordingly, the evidence received since the April 2000 RO rating decision does not raise a reasonable possibility of substantiating the claim even with VA's assistance. Shade, 24 Vet. App. at 116-18. As the Veteran has failed to submit evidence showing or even suggesting any current treatment for a left ankle disability, or any nexus opinion relating any left ankle disability to the Veteran's active service, reopening the claim is not warranted in this instance. In short, the additional evidence, while "new" is not "material," which is required to reopen the claim, because it does not indicate that the Veteran is diagnosed with a left ankle disability. Correspondingly, the new evidence does not show a link to the injury to the left ankle noted during the Veteran's active duty service. Accordingly, this additional evidence does not relate to an unestablished fact necessary to substantiate the claim or raise a reasonable possibility of substantiating the claim. Nor does the evidence meet the low threshold of 38 C.F.R. § 3.159(c)(4)(iii) , consistent with McLendon v. Nicholson, 20 Vet. App. 79 (2006), for determining whether a VA examination is necessary. See Shade, 24 Vet. App. 110. Under these circumstances, the Board must conclude that new and material evidence to reopen the claim of service connection for a left ankle disability has not been received, and the RO's decision of April 2000 remains final. In light of the foregoing, the petition to reopen the claim of service connection for a left ankle disability is denied. As new and material evidence to reopen the claim of entitlement to service connection for a left ankle disability has not been submitted, the benefit of the doubt doctrine is not applicable. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). The Merits of the Claim-Service Connection for Hypertension Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Certain chronic diseases, such as hypertension, which are listed in 38 C.F.R. § 3.309(a) may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm, or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm, or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1), under Diseases of the Arteries and Veins. These must be confirmed by readings taken two or more times on at least three different days. Id. The Board notes that the Veteran does not contend, nor does the record show, that he was clinically diagnosed with hypertension as defined under 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) within one year of his separation from service. Thus, the statutory presumption under 38 C.F.R. §§ 3.307, 3.309 does not apply in this case. If chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the present case, the Board finds after careful consideration that the evidence is at least in a state of relative equipoise on all material elements of the Veteran's claim for service connection for hypertension, for the following reasons. The Veteran contends that his current hypertension had its onset in service, as evidenced by elevated blood pressure readings and a formal diagnosis of high blood pressure in February 1990. The Board concedes that the record reflects current diagnosis of and treatment for hypertension. Further, the service treatment records show evidence of elevated blood pressure readings and a formal diagnosis of high blood pressure in February 1990, confirming the Veteran's assertion in this respect. Thus, the matter turns on the existence of a nexus and/or a showing of continuity of symptomatology since the Veteran's separation from service. As to the presence of credible and competent evidence showing the existence of a nexus between the current hypertension and the Veteran's service, the record contains three VA examinations/medical opinions addressing the claim. On VA heart examination in January 2009, the Veteran reported that elevated blood pressure levels were noted in 1984 and 1985, and that he began to take medication to treat his hypertension in 2000. The examiner noted that on enlistment examination, the Veteran was found to be in good general health and his blood pressure was noted to be normotensive on enlistment day. The examiner also noted that on separation physical, the Veteran's blood pressure was 122/62, which was also normal. The Veteran provided an onset date for his hypertension during active service in 1984, when he started noticing elevated blood pressure levels. He reported that he first began treatment with medications for his hypertension in 2000, which was after military service. The examiner noted the Veteran took Metoprolol and Lisinopril, which helped to control the blood pressure. The examiner indicated that review of medical records did not show a five-day blood pressure check or three-day blood pressure check to establish a diagnosis of hypertension while on active duty. The examiner further indicated that review of medical records did not show elevated blood pressure readings except on one or two occasions when the Veteran was "acutely ill." On physical examination, the Veteran's blood pressure readings were 148/101, 136/91 and 130/107, which was characterized as "normal." The examiner noted that hypertension had been previously diagnosed and the Veteran was on antihypertensive medication. The Veteran was diagnosed with "hypertension, essential, medically treated, controlled." The examiner opined that the hypertension was less likely than not caused by or related to the Veteran's active military service. The examiner based this opinion on a finding that the service treatment records were silent for diagnosis of hypertension. The January 2009 examiner's opinion was determined to be inadequate for VA rating purposes and another VA examination was ordered. "[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board agrees that this opinion was inadequate insofar as it failed to provide more than a cursory and conclusory explanation of why the Veteran's hypertension was unrelated to his service. In this regard, the examiner failed to address the diagnosis of high blood pressure noted in the service treatment records, or the service treatment records showing high blood pressure readings. Without such reasoning, the Board is unable to assign more than minimal probative weight to the examiner's conclusions; thus, it is insufficient to decide the matter. See Nieves-Rodriguez, 22 Vet. App. at 304. See also, Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (finding that "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion"). Thus, in April 2011, an addendum opinion was provided by a new VA examiner in conjunction with a VA joints examination. The examiner provided a more thorough review of the claims file, and listed the Veteran's elevated blood pressure readings from his time in service. Specifically, the examiner identified blood pressure readings of 150/98 on August 18, 1987; 140/100 on February 25, 1988; 160/100 on November 20, 1989; and 152/110 on January 12, 1990, when the Veteran presented with complaints of unrelated illness. The examiner also noted a February 12, 1990 service treatment record, which indicated that the Veteran received acute medical care during a visit to the battalion aid station, which showed high blood pressure as the Veteran's chief complaint. The examiner indicated that the initial blood pressure showed a reading of 140/90 and repeated blood pressure showed a reading of 150/110 on the left arm and 138/108 on the right arm. The examiner noted that the Veteran's medical examination at that time was essentially normal, and he was diagnosed with high blood pressure and referred to the outpatient clinic for follow-up. The examiner indicated that an entry on a record of acute medical care, also dated February 12, 1990, showed that the Veteran followed-up at the outpatient clinic as directed and his blood pressure reading was 130/72. The examiner observed that no other notes were found in the medical record to indicate continued follow-up or treatment for high blood pressure. The examiner noted that findings in the service treatment records also showed that the Veteran was evaluated on January 6, 1992 and January 8, 1992 for chest pain and elevated blood pressure. The examiner observed that the findings in the service treatment records showed an elevation of the Veteran's blood pressure on multiple occasions due to unrelated illness; however, on February 12, 1990, the Veteran presented to medical with a chief complaint of high blood pressure readings, and both arms showed significant elevation of his blood pressure, 150/110 on the left, and 138/108 on the right. The examiner again noted that the Veteran was diagnosed with high blood pressure and was instructed to follow up at an outpatient clinic, which he did, but there was no evidence that he received treatment for his high blood pressure while in service. The examiner noted that the Veteran began treatment for hypertension shortly after separation from active duty, and opined that the Veteran's current hypertension was at least as likely as not cause by or the result of progression of the high blood pressure readings shown during active duty. The Board finds that the April 2011 addendum opinion is particularly persuasive as the examiner's opinion is informed by a thorough review and analysis of the Veteran's service treatment records. Further, it reflects a clear and unequivocal opinion relating hypertension to the Veteran's treatment for high blood pressure in service. Finally, the physician explained that the Veteran's elevated blood pressure readings were taken on occasions due to unrelated illness, and that his current hypertension was caused by or the result of the high blood pressure readings shown during active duty. This reasoning, albeit brief, adequately shows that the examiner's conclusions are supported by the relevant and material information. In short, the April 2011 addendum opinion is factually accurate, fully articulated, and based on sound reasoning. Thus, it carries significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In June 2012, a third VA examination (also known in the record as a Disability Benefits Questionnaire or "DBQ") was obtained, in an apparent attempt to clarify the April 2011 addendum opinion. The new VA examiner reviewed the January 2009 and April 2011 conflicting VA medical opinions, and referred discussion of the history of the Veteran's current medical complaints to the April 2011 opinion. The examiner proceeded to address the Veteran's service treatment records, noting that a separation examination, dated on February 29, 1984, was negative for hypertension, and the Veteran's blood pressure reading was 132/70, yet the Veteran reported that he began to notice he had elevated blood pressure. The examiner observed that an August 18, 1987 consult note showed the Veteran was treated for an injury to his face, and his blood pressure reading was 150/98. A February 25, 1988 consult note showed treatment for gonorrhea, and the blood pressure reading was 140/100. A November 30, 1989 consultation note showed treatment for urethritis, and the blood pressure reading was 160/100. The examiner observed that the Veteran was not prescribed blood pressure medication at any point during this treatment. A January 12, 1990 treatment record showed the Veteran presented with complaints of unrelated illness, and the blood pressure reading was 152/110. However, the examiner noted that no definite diagnosis of hypertension was made and the Veteran was not prescribed blood pressure medication. On February 12, 1990, a consultation at a battalion aid station report showed the Veteran was treated for high blood pressure, and that the initial reading was 140/90, and repeated readings showed 150/110 on the left arm and 138/108 on the right arm. The Veteran was diagnosed with high blood pressure and was referred to an outpatient clinic for follow-up. The examiner noted that no blood pressure medication was prescribed at the time. The examiner noted that on outpatient follow-up on February 12, 1990, the Veteran's blood pressure reading was 130/72 and no other notes were found in the medical record to indicate continued follow-up or treatment for high blood pressure. The examiner also noted that on examination in July 1990, the Veteran indicated that he had high blood pressure, and in January 1992, he reported a history of elevated blood pressure. However, on separation examination in February 1992, the Veteran had a normal blood pressure reading of 122/62. The examiner indicated that the Veteran reported that he began to take blood pressure medication in 2000. The examiner also indicated that review of medical records did not show a five-day or a three-day blood pressure check to establish a diagnosis of hypertension while in active military service. The examiner noted that review of the medical record did not show elevated blood pressure readings except on one or two occasions when the Veteran was acutely ill, as per the history taken from the 2009 VA examination report. The examiner observed that in April 2008 the Veteran was diagnosed with hypertension for which he was prescribed Metoprolol. Also, he was diagnosed with essential hypertension on VA examination in 2009. The examiner opined that the Veteran's hypertension was less likely than not related to his active service. The examiner explained that the service treatment records documented elevated blood pressure readings; however, they were taken concomitant with acute medical conditions, such as injury to the face and recurrent gonorrhea, which are stressful events and can promote transient blood pressure elevations. The examiner noted that no blood pressure medications were prescribed during these consults. The examiner also observed that there was no definite diagnosis of and treatment for hypertension in service, and there was no objective evidence of three-day or five-day blood pressure monitoring shown during active service. The examiner noted that on separation examination, the Veteran had a normal blood pressure reading of 122/62. The examiner also noted that although his blood pressure was elevated, the Veteran was not prescribed medication until 2000, and was not diagnosed with essential hypertension until 2008. The Board accords the June 2012 VA examination opinion little probative value as review of the service treatment records clearly refute the examiner's contention that the Veteran's high blood pressure readings were solely taken concomitant with acute medical conditions that were stressful events and could promote transient blood pressure evaluations. In this regard, when taken as a whole, the Veteran's service treatment records spanning his approximately ten years of service show an upward trend in his blood pressure readings, regardless of treatment for a variety of illnesses and injuries. Despite treatment for a variety of illnesses and injuries, the Veteran's blood pressure readings appeared to elevate under a plethora of stressful conditions, and to remain lower under similar conditions. Thus, the examiner's argument which relies upon a finding that the service treatment records showing treatment for "stressful events" that could promote transient blood pressure evaluations is not found to be persuasive. Accordingly, the Board is unable to assign more than minimal probative value to the June 2012 VA examiner's opinion. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, the Board observes that the Veteran has attested to his long-term treatment for hypertension, which, as a lay person, he is competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (2007) (lay evidence can be competent to establish diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms supports a later diagnosis by a medical professional). Further, the Board considers the Veteran's assertions of a continuity of hypertension symptomatology since service to be credible in the absence of any evidence expressly negating those assertions. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (finding that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). As hypertension is considered a chronic disease under 38 C.F.R. § 3.309(a), service connection can be granted for this disease by establishing continuity of symptomatology since service under 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted above, when, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail."). Because there is evidence of numerous high blood pressure readings and a diagnosis of high blood pressure in service, and subsequent medical findings of hypertension thereafter, as well as credible supporting evidence of a chronic hypertension disorder since service and a positive nexus opinion linking the Veteran's current hypertension to his high blood pressure in service, the Board concludes that the evidence supports the grant of service connection for hypertension. Thus, following a full review of the record, and applying the benefit of the doubt doctrine, all doubt is resolved in favor of the Veteran. See 38 C.F.R. § 3.102. Therefore, the Veteran's claim for service connection for hypertension is granted. ORDER New and material evidence has not been received to reopen a claim for entitlement to service connection for a left ankle disability and the request to reopen is denied. Service connection for hypertension is granted. REMAND The record as it stands is inadequate for the purpose of rendering a fully informed decision as to the remaining claim that has been certified for the Board's review at this time. Where the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order to fulfill the statutory duty to assist the Veteran in developing facts pertinent to the claim. Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). The Veteran asserts that his heart disability, to include mild atherosclerotic cardiovascular disease and a history of myocardial infarction, is related to his now-service-connected hypertension. He provided written and oral testimony that he experienced chest pains on several occasions in service, but that there was no follow-up to determine the cause of the chest pains. A disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Secondary service connection may be established by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b), effective October 10, 2006. See 71 Fed. Reg. 52,744-52,747 (September 7, 2006). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. A claim for secondary service connection requires competent medical evidence linking the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). See also Wallin v. West, 11 Vet. App. 509, 512 (1998) and McQueen v. West, 13 Vet. App. 237 (1999) (both indicating, like Velez, that competent medical nexus evidence is required to associate a disorder with a service-connected disability). In short, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). In January 2009, the Veteran underwent a VA heart examination, during which he provided a history of a myocardial infarction in March 2008, for which he was hospitalized for one week. The examiner indicated the onset of the Veteran's heart condition developed after his active military service. The examiner noted the Veteran had three days of discomfort, chest tightness and body aches that he thought were the flu. The examiner indicated that the Veteran did not have a history of previous coronary artery disease or cardiomyopathy, but did have a history of hyperlipidemia that was untreated. The Veteran underwent a cardiac catheterization at that time, which revealed an impression of atherosclerotic cardiovascular disease; 70 percent proximal small ramus; normal left ventricular function; and small enzymatic myocardial infarction. The examiner noted that the Veteran also had an echocardiogram at that time, the interpretation of which revealed an abnormality consistent with ischemic cardiomyopathy associated with severe mitral insufficiency. The examiner noted the Veteran had coronary risk factors of a previous history of smoking, dylipidemia and obesity. Following an evaluation, the Veteran was diagnosed with atherosclerotic cardiovascular disease; left ventricular hypertrophy; left atrial hypertrophy; mild mitral insufficiency; estimated ejection fraction 58 percent, normal; and METS seven. The examiner opined that this condition was less likely than not caused by or secondary to hypertension or active military service. The examiner explained that the Veteran had other risk factors, including a smoking history, hyperlipidemia and obesity. The Board finds this opinion, the only of record addressing the nature and etiology of the Veteran's claimed heart disability, to be deficient for the purpose of addressing the matter of service connection. First, the examiner failed to address the service treatment records, which clearly showed complaints of and treatment for repeated instances of chest pain. The probative value of medical opinion evidence, among other factors, is based on whether a clinician was "informed of the relevant facts" and medical history in rendering a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Second, the opinion as to the relationship between the Veteran's heart disability and his military service is cursory and conclusory. In this regard, the examiner failed to explain why the Veteran's other risk factors were more likely the cause of his heart disability. Without such reasoning, the Board is unable to assign more than minimal probative weight to the examiner's conclusions; thus, it is insufficient to decide the matter. See Nieves-Rodriguez, 22 Vet. App. at 304. Third, the Board finds that the opinion does not adequately address the two separate questions comprising a secondary service connection theory of entitlement: causation and aggravation. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). In particular, the Board finds that use of the phrase "not caused by or secondary to" by the VA examiner did not sufficiently address whether or not the Veteran's hypertension aggravated the heart disability. Accordingly, this examination report is not adequate to decide the case. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Hence, the Board finds an additional VA examination and medical opinion is required for an adequate determination of the etiology of the Veteran's heart disability. See 38 U.S.C.A. § 1110, 1131, 1310 (West 2002); 38 C.F.R. § 3.303, 3.304 (2012). Accordingly, the Board finds that a new examination and opinion is in order. McLendon v. Nicholson, 20 Vet. App. 79 (2006). This review must be conducted with a review of the claims folder including Virtual VA. As noted, he Court has held that the Board may not rely upon its own unsubstantiated medical opinion. Allday v. Brown, 7 Vet. App. 517 (1995); Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC must arrange for a VA cardiology examination with an appropriate clinician to determine the nature and etiology of any cardiopathology diagnosed. All indicated studies and tests are to be performed. A copy of this remand and all relevant medical records should be made available to the examiner, to include any pertinent records in the Virtual VA Folder. The examiner is asked to confirm whether paper and/or electronic records were available for review. After reviewing the claims files, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (50 percent probability or more) that any diagnosed heart disability had its onset during service, became manifest within one-year of his discharge from service, or is otherwise causally related to any event or circumstance of his active service? (b) Without regard to the answer to question (a), whether it is at least as likely as not (50 percent probability or more) that any current heart disability, is either (1) proximately due to, the result of, or caused by a service-connected disability, to particularly include hypertension; or, in the alternative, (2) has been aggravated (made permanently worse beyond the natural progression of the disease) by any service-connected disability, to particularly include hypertension. It is imperative that the examiner provide a clear and separate response addressing these two distinct questions, involving causation and aggravation, for each claimed disability. In providing answers to the above questions, the examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. In making all determinations, the examiner is asked to carefully consider the Veteran's own assertions and any lay assertions of record, including the testimony of his spouse. The examiner is advised that the Veteran is competent to report his symptoms, and that his reports must be considered in formulating the requested opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for any opinion offered is requested. If the examiner is unable to render the requested opinion without resort to pure speculation, he or she must so state; however, a complete rationale for such a finding must be provided. 2. Thereafter, the RO/AMC must consider all of the evidence of record and readjudicate the claim for service connection. If the benefit sought is not granted, the RO/AMC must issue a supplemental statement of the case and allow the Veteran and his representative an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs