Citation Nr: 1321900 Decision Date: 07/09/13 Archive Date: 07/18/13 DOCKET NO. 06-05 018 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a left knee disability to include injury residuals and posttraumatic arthritis. 2. Entitlement to service connection for a gastrointestinal disorder to include gastroesophageal reflux disease (GERD) and acid reflux. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1979 to November 1987. He also had service with the Air Force Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Veteran testified at a hearing before a Decision Review Officer (DRO) in February 2006. The Veteran requested a hearing before the Board when he filed his substantive appeal in February 2006. The Veteran was scheduled for a hearing before the Board in March 2008; however, in February 2008, he requested that the hearing be rescheduled. In an August 2008 letter, the Veteran was advised that his hearing before the Board was rescheduled for September 2008. The Veteran failed to report for the hearing in September 2008. His request for a hearing is therefore treated as withdrawn. 38 C.F.R. § 20.704(d). In March 2010, September 2011, and September 2012 the Veteran's claims were remanded by the Board for additional development. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issue of entitlement to service connection for a gastrointestinal disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's currently diagnosed left knee disability to include injury residuals and posttraumatic arthritis is not related to his military service nor was an injury that pre-existed periods of active duty for training and inactive duty for training aggravated in the line of duty. CONCLUSION OF LAW A left knee disability to include injury residuals and posttraumatic arthritis was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran seeks entitlement to service connection for a left knee disability to include injury residuals and posttraumatic arthritis. In the interest of clarity, the Board will discuss certain preliminary matters. The issue on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in March 2010, September 2011, and September 2012, the Board remanded this claim and ordered the agency of original jurisdiction (AOJ) to verify the Veteran's periods of service as well as schedule the Veteran for a VA examination with regard to his left knee disability. The Veteran's claim was then to be readjudicated. Pursuant to the Board's remand instructions, the Veteran's periods of military service were verified. Additionally, the Veteran was afforded VA examinations for his left knee disability and reports of the examinations were associated with his claims folder. The Veteran's left knee claim was readjudicated via a March 2013 supplemental statement of the case (SSOC). Accordingly, the Board's remand instructions have been substantially complied with regarding the Veteran's left knee disability claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by a letter mailed in May 2004, and notice with respect to the disability rating and effective-date elements of the claim by way of a March 2006 letter. Although the March 2006 letter pertaining to the disability rating and effective-date elements of the claim was provided after the initial adjudication of the claim, the Board finds that the Veteran has not been prejudiced by the timing of these letters. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the VA Appeals Management Center (AMC) readjudicated the Veteran's claim in August 2012 and March 2013 SSOCs. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claim and there is no reasonable possibility that further assistance would aid in substantiating this claim. The evidence of record includes the Veteran's statements, service treatment records, photographs, as well as postservice VA and private treatment records. Additionally, the Veteran was afforded VA examination for his left knee in November 2012. The VA examination report reflects that the examiner interviewed and examined the Veteran, reviewed his past medical history, reviewed his claims folder, documented his current medical conditions, and provided sufficient information such that the Board can render an informed determination. The Board therefore concludes that the VA examination report for the Veteran's left knee is adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. Thus, the Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. He has retained the services of an accredited representative. He failed to appear for his scheduled Board hearing. However, he presented testimony before a DRO in February 2006. With respect to the aforementioned DRO hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the DRO noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions concerning a nexus between current disability of the left knee and service as well as his treatment history. The DRO specifically asked whether the Veteran's private physician had linked the left knee disorder to the 1983 injury in service. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Accordingly, the Board will proceed to a decision as to the issue of entitlement to service connection for a left knee disability to include injury residuals and posttraumatic arthritis. Service connection for left knee disability Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including arthritis, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See 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. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In order to show a 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). The term "Veteran" is defined in 38 U.S.C.A. § 101(2) as "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." The term "active military, naval, or air service" includes active duty, and "any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty." 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a) (2012); Biggins v. Derwinski, 1 Vet. App. 474, 477-478 (1991). Active duty for training (ACDUTRA) is defined, in part, as "full-time duty under sections 316, 502, 503, 504, or 505 of title 32 [U. S. Code] or the prior corresponding provisions of law." 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). The term inactive duty training (INACDUTRA) is defined, in part, as duty, other than full-time duty, under sections 316, 502, 503, 504, or 505 of title 32 [U. S. Code] or the prior corresponding provisions of law. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Thus, with respect to the Veteran's Reserve service, service connection may only be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303, 3.304. Service connection is generally not legally merited when a disability incurred on INACDUTRA results from a disease process. See Brooks v. Brown, 5 Vet. App. 484, 487 (1993). Certain evidentiary presumptions -- such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases, such as arthritis, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service--are provided by law to assist Veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. §§ 101, 1112; 38 C.F.R. § 3.304(b), 3.306, 3.307, 3.309. However, the advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that, "if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve Veteran status for purposes of that claim."). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran is claiming entitlement to service connection for a left knee disability to include injury residuals and posttraumatic arthritis, which he contends is due to his active military service. As to Hickson element (1), the Board observes that the medical evidence of record includes diagnoses of chondromalacia patellae and posttraumatic arthritis. See, e.g., November 2011 and November 2012 VA examination reports. As such, Hickson element (1) is, therefore, satisfied. With regard to Hickson element (2), evidence of an in-service incurrence of a disease or injury, the Board will address disease and injury separately. Concerning in-service disease, a review of the Veteran's available service treatment records reveals no evidence of any diagnosed left knee disability. Additionally, the record does not reflect medical evidence showing any manifestations of arthritis of the left knee during the one-year presumptive period after the Veteran's separation from active duty. On the contrary, the record does not reflect any complaints or medical evidence of manifestation of arthritis of the left knee prior to May 2004 (more than 15 years after his separation from active service). Accordingly, Hickson element (2) is not met with respect to disease. With respect to in-service injury, the Veteran asserts that he sustained a traumatic left knee disorder as the result of an in-service February 1983 parachute landing fall training exercise. He has testified that did not report the injury to the military authorities as he was afraid that he would lose his flying status. The Board notes the Veteran is competent to attest to experiencing an injury to his knee. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Therefore, although the Veteran as a lay person has not been shown to be capable of making medical conclusions, he is competent to report the circumstances of in-service knee injury. There is nothing in the claims folder to suggest that the Veteran did not sustain the injury as described during his DRO hearing. Accordingly, evidence of an in-service injury is arguably met. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record supports a finding that the Veteran's current left knee disability is not related to his military service. In this regard, the evidence includes a private medical record dated in March 2004 indicating that the Veteran injured his left knee in the military in 1983 during a parachute landing. As the medical record does not indicate that the Veteran has a knee disability that is due to an injury during active service or as a result of aggravation of the 1983 injury during a period of ACDUTRA or INACDUTRA, it is not entitled to probative weight. The Veteran underwent a VA examination in June 2007. The examiner noted that the Veteran reportedly twisted his knee while practicing a parachute landing in 1983. The examiner diagnosed left knee strain and noted that the service records do not show any evidence of a left knee injury in 1983. The examiner noted a review of the claims folder and found that it was less likely as not that any current left knee condition was related to any injury in 1983 and that there was no evidence to support any worsening or aggravation of any left knee condition while on reserve duty. As the dates of service had not been verified and as the examiner did not consider the Veteran's lay testimony of an injury in service, the Board remanded the claim in March 2010 for another examination. The Veteran underwent another VA examination in November 2010. The examiner reviewed the claims folder, examined the Veteran and provided an opinion that it was less likely than not that the active duty service or Reserve service would have aggravated his left knee condition any more than normal progression. The examiner noted that the exam was unremarkable and the left knee x-ray was normal. The examiner did not consider whether a left knee disorder shown during the appeal period was due to the 1983 injury. Accordingly, the Board remanded the claim in September 2011 for another examination. In that regard, the Veteran was afforded a VA examination for his left knee in November 2012. Pertinently, the VA examiner considered the Veteran's complaints of chronic left knee pain as well as his in-service injury from practicing parachute landings in 1983. After examination of the Veteran and consideration of his complaints of chronic left knee pain and in-service injury in 1983, the VA examiner concluded that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The examiner's rationale for his conclusion was based on his review of the Veteran's medical history, to include a diagnosis of posttraumatic arthritis in March 2005 by P. Matherne, M.D. and normal X-ray findings in October 2010 and September 2012 as well as the absence of treatment for a left knee disability until March 2004. He also noted a review of medical literature, specifically noting that current studies performed by the U.S. military at trauma centers suggest that traumatic arthritis associated to significant trauma (bullets, fragments, severe trauma, etc.) will be established within three years from the date of the injury. The November 2012 VA examination report was based upon a review of the record, examination of the Veteran, and the opinion was supported by a rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. Additionally, in rendering the opinion, the VA examiner considered the Veteran's service treatment records, his in-service report of left knee injury in 1983, and his report of longstanding left knee pain, and indicated that his military service did not cause his current left knee disability. The Board observes that a March 2005 written statement from Dr. Matherne relates that the Veteran had been seen for chronic left knee pain "that apparently occurred on an on-the-job injury in about 1983 when he parachuted and landed on his knee." The doctor advanced a diagnostic impression of posttraumatic arthritis and opined that the current disability is from the in-service injury. Crucially, however, Dr. Matherne did not render a rationale as to why the Veteran's current left knee disability is related to his military service. See Hernandez- Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the health care provider to provide a basis for his/her opinion goes to the weight or credibility of the evidence]. On the contrary, as discussed above, the November 2012 VA examiner specifically noted that multiple X-rays of the Veteran's left knee which were taken following his discharge from service were normal and also noted the absence of treatment for a left knee disability until March 2004. Moreover, the November 2012 VA examiner referenced the findings of Dr. Matherne and indicated that posttraumatic arthritis should have been established within three years from the date of the Veteran's in-service injury. Notably, physical examinations of the Veteran conducted by the Reserves in January 1991, January 1993, January 1996, January 1998 and January 2001 indicate that his lower extremities are normal. As a rationale was not provided, the Board finds the March 2005 statement from Dr. Matherne to be of no probative value in determining whether the Veteran's current left knee disability is related to his military service. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including left knee pain), as a lay person is not competent to associate any of his claimed symptoms to his military service. The Board finds that the Veteran as a lay person is not competent to associate currently diagnosed knee disabilities, including arthritis, chondromalacia, and tendonitis, to his military service. Such opinion requires specific medical training and is beyond the competency of the Veteran or any other lay person to observe. In the absence of evidence indicating that the Veteran has the medical training to render medical opinions, the Board must find that his contention with regard to a nexus to be of no probative value. See also 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). Accordingly, the statements offered by the Veteran in support of his own claims are not competent evidence of a nexus. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. The Board notes that the Veteran appears to be contending that he has had left knee symptomatology continually since active service. While the Veteran is competent to report left knee symptomatology over the years since service, the Board finds that his statements are not credible in light of the multiple Reserve examinations after his active service which found that his lower extremities were normal. The Board therefore finds that the Veteran's current statements regarding a continuity of left knee disability since active service which ended in November 1987 are not credible. The Veteran's assertion is that he has a current left knee disability as a result of an injury during active service in 1983. He has not asserted that a left knee disease or injury pre-existed that period of active service. He also did not assert that his left knee disorder was aggravated during a subsequent period of ACDUTRA or INACDUTRA. Nevertheless, pursuant to the Board's request, the November 2010 VA examiner, who had access to the Veteran's dates of service, opined that it was less likely than not that Reserve service would have aggravated the left knee condition any more than normal progression. The examination report in this regard is not inadequate. The examiner indicated a review of the claims folder and the Board notes that the Reserve records show the Veteran had multiple normal examinations of the lower extremities from 1991 to 2001. The evidence, including the Veteran's statements, does not show that the Veteran's left knee injury was aggravated during a period of ACDUTRA or INACDUTRA. Accordingly, Hickson element (3) is not met, and the Veteran's claim fails on this basis. In conclusion, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a left knee disability to include injury residuals and posttraumatic arthritis. The benefit sought on appeal is accordingly denied. ORDER Entitlement to service connection for a left knee disability to include injury residuals and posttraumatic arthritis is denied. REMAND Service connection for a gastrointestinal disability The Board remanded the case in September 2012 in order for the AOJ to schedule the Veteran for a VA examination in order to determine whether his gastrointestinal disability such as GERD is related to his active service. The examiner was specifically requested to consider the Veteran's report that the condition manifested during the time in active service when he was required to consume box lunches while participating in aerial flight and the stress associated with his flight-related service duties. The examiner was to also consider the Veteran's statements regarding his symptoms in service and statements of continuous gastrointestinal symptoms since service. The Veteran's claim was then to be readjudicated. Unfortunately, the Board finds that an additional remand is necessary prior to review of the Veteran's claim. The Board notes that the Veteran was afforded a VA examination for his gastrointestinal disability in November 2012. The examiner noted the Veteran's report that he started having problems with indigestion in 1995 or 1996 and that he has taken Prilosec for treatment since 1999. The Veteran also reported symptoms of infrequent episodes of epigastric distress, pyrosis, reflux, and sleep disturbance caused by esophageal reflux. After examination of the Veteran, the VA examiner diagnosed the Veteran with dyspepsia and concluded that his dyspepsia is less likely as not related to or caused by his active duty service. The VA examiner's rationale for his conclusion was based on his finding of no treatment for gastrointestinal symptoms until March 2004. He also noted upper gastrointestinal radiographic series dated August 2010 and September 2011 which were essentially normal. He therefore found no significant GERD by these two radiographic studies. He also reported that the Veteran's service treatment records did not support a chronic or ongoing upper gastrointestinal condition. Crucially, however, the VA examiner did not consider the Veteran's report that the gastrointestinal disability manifested during the time in service when he was required to consume box lunches while participating in aerial flight and the stress associated with his flight-related service duties. The examiner also did not consider the Veteran's statements regarding his symptoms in service and statements of continuous gastrointestinal symptoms since service. In light of the foregoing, the Board finds that another remand is required for compliance with its September 2012 Remand instructions. See Stegall v. West, 11 Vet. App. 268, 270 (1998) (holding that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand). Accordingly, the case is REMANDED for the following action: 1. The RO should obtain a supplemental opinion from the November 2012 VA examiner with regard to the Veteran's gastrointestinal disability. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the examiner. In addition to the service treatment records, the November 2012 VA examiner must consider the Veteran's statements regarding his symptoms in service and his statements of continuous gastrointestinal symptoms since service. Dalton v. Nicholson, 21 Vet App. 23 (2007). The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or more probability) that the Veteran's gastrointestinal disability is related to his active service from August 1979 to November 1987 or subsequent periods of active duty for training with the Reserves, including his report that the condition manifested during the time that he was required to consume box lunches while participating in aerial flight and the stress associated with his flight-related service duties. Please provide a complete explanation for the opinion. The examiner should also address whether the gastrointestinal disability was at least as likely as not aggravated (i.e., permanently worsened) beyond the natural progress during a period of active duty for training with the Reserves. Please provide a complete explanation for the opinion. 2. After the above is complete, ensure the examination report is adequate, conduct any additional development deemed warranted and then readjudicate the Veteran's gastrointestinal disability claim. If the claim remains denied, issue a supplemental statement of the case (SSOC) to the Veteran and his representative, and they should be given an opportunity to respond, before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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). ______________________________________________ S.S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs