Citation Nr: 1322658 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-44 385 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a skin condition. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran had active military service from June 1967 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In August 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. In September 2012, the Board reopened and remanded the claims for additional development. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, his preexisting left ear hearing loss was aggravated during service. 2. Resolving all reasonable doubt in the Veteran's favor, his right ear hearing loss was incurred in service. 3. The Veteran's tinnitus is secondary to his bilateral hearing loss. 4. The Veteran does not have a diagnosis of chloracne or another acneform disease consistent with chloracne. 5. The preponderance of the evidence does not show that the Veteran's current skin disorder, diagnosed as acitinic or seborrheic keratosis, was incurred in or is related to his military service, to include herbicide exposure therein. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306, 3.307, 3.309, 3.385 (2011). 2. The criteria for service connection for tinnitus have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. The criteria for service connection for a skin disorder have not been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify & Assist Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In this decision, the Board grants service connection for bilateral hearing loss and tinnitus. As this represents a complete grant of those benefits sought on appeal, no discussion of VA's duty to notify and assist is necessary as to those issues. Regarding the skin disorder claim, in October 2008 and September 2012 letters, VA notified the Veteran of the information and evidence needed to reopen and substantiate his claim of entitlement to service connection, to include notice of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain. VA also informed the Veteran of how disability evaluations and effective dates are assigned. The notice was timely because the claims were readjudicated in the February 2013 supplemental statement of the case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). As to the duty to assist, VA obtained VA treatment records, private medical records and employment records. The Veteran has not indicated there are any additional records that VA should seek to obtain on his behalf. VA has provided the Veteran with examinations in connection with his skin disorder claim on appeal, most recently in October 2012. The October 2012 medical opinion provided is adequate for adjudicative purposes. The examiner reviewed the claims file, discussed the pertinent evidence of record, and provided a rationale for the ultimate conclusion. In its September 2012 remand, the Board requested that (1) VA associate any temporary folders maintained at the RO; (2) provide the Veteran with a new VCAA notice letter; (3) obtain outstanding VA treatment records; (4) ask the Veteran to identify any outstanding sources of treatment and request any records identified by the Veteran; and, (5) provide the Veteran with a VA examination. In September 2012, VA sent the Veteran a notice letter and requested information and releases pertaining to outstanding sources of treatment for his disabilities on appeal. However, the Veteran did not respond. The "duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Additionally, VA associated the Veteran's temporary folder with the claims file in September 2012. The Veteran was also provided a VA examination pertaining to his skin disorder in October 2012. The examiner addressed the likelihood of whether the disability was incurred in or aggravated by service and provided a rationale of the opinion that was based upon medical principles and evidence in the claims file. For these reasons, the Board finds there has been substantial compliance with the Board's instructions in obtaining additional evidence. VA has also provided the Veteran with a hearing before a Veterans Law Judge in connection with the appeal. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer 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, during the August 2011 hearing, the undersigned Veterans Law Judge explained the issues involved and asked questions directed at identifying whether the Veteran had symptoms meeting the schedular criteria for service connection. The VLJ further sought to identify any pertinent evidence not currently associated with the claims, including sources of treatment for the Veteran's skin disorder. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). For the above reasons, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. 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). II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(table). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a Veteran had a chronic condition in service or during the applicable presumptive period. In addition, certain chronic diseases, including organic diseases of the nervous system (such as sensorineural hearing loss), may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In addition, a disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310 (2012). Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Establishing service connection on a secondary basis essentially requires evidence sufficient to show that a current disability exists, and that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. §§ 3.303, 3.310. A veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. Only such conditions as are recorded in physical examination reports are to be considered as "noted." Paulson v. Brown, 7 Vet. App. 466, 470 (1995). Clear and unmistakable evidence means that the evidence cannot be misinterpreted or misunderstood, i.e., it is undebatable. Quirin v. Shinseki, 22 Vet. App. 390, 396 (citing Vanerson v. West, 12 Vet. App. 254, 258-59 (1999). In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service, and then whether this constitutes an increase, permanent in nature, in the disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). A preexisting condition will be considered to have been aggravated by military service where there is an increase in disability during that service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. The presumption of aggravation is triggered by evidence that a preexisting disability has undergone a permanent increase in severity during service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Sondel v. West, 13 Vet. App. 213 (1999); Beverly v. Brown, 9 Vet. App. 402 (1996). However, aggravation of a pre-existing injury may not be conceded where the disability underwent no increase in severity during service, on the basis of all the medical evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R.§ 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, not just the symptoms, has worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991); Verdon v. Brown, 8 Vet. App. 529, 536-37 (1996), Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Crowe v. Brown, 7 Vet. App. 238, 247-8 (1994); Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993). If a preexisting disorder becomes worse during service, and then improves due to in-service treatment to the point where it was no more disabling that it was on entry into the service, the disorder is not presumed to have been aggravated by service. Verdon, 8 Vet. App. 529. The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). If a veteran served in Vietnam during the period from January 9, 1962, to May 7, 1975, he or she will be presumed to have been exposed to herbicides during such service. Certain diseases (including chloracne or other acneform disease consistent with chloracne) will be presumed service-connected due to such exposure, even if there is no record of the disease during service. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). It is acknowledged that in a recent Federal Circuit decision, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Because sensorineural hearing loss is considered an organic disease of the nervous system, and there is a diagnosis of sensorineural hearing loss of record, the claim is subject to consideration of entitlement to service connection based upon continuity of symptomatology under 38 C.F.R. § 3.309(a). However, neither chloracne nor actinic keratosis is recognized as a chronic disease under 38 C.F.R. § 3.309(a) and therefore, the Veteran's skin disorder claim is not subject to the same consideration. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, all reasonable doubt shall be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Hearing Loss and Tinnitus Here, the Veteran asserts that his current hearing loss and tinnitus are due to noise exposure during service without the use of hearing protection. Specifically, the Veteran asserts that his current hearing loss and tinnitus are the result of exposure to noise from turbine engines while performing aircraft maintenance in service. He further argues that any preexisting hearing loss was aggravated by his service. The Board first finds that the Veteran has a current bilateral hearing loss disability. Impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Here, testing during January 2009 and October 2012 VA examinations revealed pure tone thresholds of 40 decibels or greater at every frequency tested for the left ear, and at the 3000 and 4000 Hertz levels for the right ear. Additionally, the January 2009 examination revealed a speech reception threshold below 94 percent for the right ear. As such, there is a current bilateral hearing loss disability. The Board also notes that the Veteran has current a diagnosis of tinnitus, as indicated on the January 2009 and October 2012 VA examination reports. Next, the Veteran's separation document, DD Form 214, confirms that the Veteran served with an aviation battalion and his military occupational specialty was crew chief with duties relating to aircraft mechanics, maintenance, and repair. Moreover, the Veteran is competent to report his history of noise exposure in service, as it is factual in nature and within the realm of his personal observation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Barr, 21 Vet. App. at 307-08; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds that the Veteran's reports of noise exposure in service are consistent with the duties required for his military occupational specialty and concedes that the Veteran likely had noise exposure in service. Thus, the remaining question is whether the Veteran's current hearing loss and tinnitus are related to his noise exposure in service. Service treatment records show that during a November 1966 pre-induction examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 5 (15) 5 (15) X 5 (10) LEFT 15 (30) 20 (30) 25 (35) X 15 (20) Impairment of hearing was listed as a defect or diagnosis, although it was noted as "NCD," or not considered disabling. The Veteran was assigned an H-2 profile but was found qualified for military service. Prior to November 1967, audiometric results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization-American National Standards Institute (ISO-ANSI). In order to facilitate data comparison for VA purposes, ASA standards noted in service treatment records dated prior to November 1, 1967, must be converted to ISO-ANSI standards. In light of the date of the pre-induction examination, the Board has converted the results above and the ISO-ANSI conversions are provided in parentheses. Based on these conversions, the record shows the Veteran had pre-existing left ear hearing loss by VA standards as he had a pure tone threshold greater than 26 decibels at three frequencies. See 38 C.F.R. § 3.385 (2012). In August 1967, the Veteran complained of hearing problems. His right ear was "ok" on physical examination, but the left ear showed the external canal to be slightly inflamed. The left tympanic membrane was not inflamed, but there appeared to be fluid behind it. The impression was left serous otitis. Service treatment records also contain an audiogram dated August 15, 1967. Though the findings were not interpreted in the service records, it appears that the pure tone thresholds were approximately as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) 5 (15) -5 (5) 0 (5) LEFT 10 (25) 15 (25) 20 (30) 15 (25) 20 (25) In light of the date of the audiogram, the Board has converted the results above and the ISO-ANSI conversions are provided in parentheses. While not sufficient to qualify as a hearing disability for VA purposes, the foregoing findings show some degree of hearing loss in the left ear. Hensley v. Brown, 5 Vet. App. 155, 157 (1993) (pointing out that defective hearing is clinically indicated when pure tone thresholds are over 20 decibels, notwithstanding VA's definition of impaired hearing in 38 C.F.R. § 3.385). During a subsequent September 1967 flight physical, the Veteran reported that he had fluid in his left ear in 1967. A hearing test was conducted in September 1967 as well. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 (40) 15 (25) 10 (20) 5 (15) 10 (15) LEFT 20 (35) 10 (20) 15 (25) 15 (25) 10 (15) In light of the date of this flight physical, the Board has converted the results above and the ISO-ANSI conversions are provided in parentheses. Based on these conversions, the record shows the Veteran had right ear hearing loss by VA standards as he had a pure tone threshold of 40 decibels at 500 Hertz in the right ear. See 38 C.F.R. § 3.385. The Veteran did not have left ear hearing loss for VA purposes at that time. No diagnosis of hearing loss or tinnitus was made. Another flight physical was conducted in September 1968. A hearing test was conducted and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 X 15 LEFT 10 10 10 X 10 In light of the date of this flight physical, and because "ISO" is noted on the report, the results are already in ISO-ANSI standards. At the time of this physical, hearing loss for VA purposes was not evident in either ear. In January 1969, the Veteran reported to sick call requesting to have his ears checked. He reported that he been unable to hear out of his left ear for one week. His ears were irrigated with water and were characterized as "ears ok." Thereafter, also in January 1969, the Veteran underwent a separation examination during which he reported ear trouble. Unfortunately, a hearing test was not conducted at the time of the separation examination. Post-service employment records contain hearing tests showing hearing impairment for VA purposes in the right ear as early as September 1982 and in the left ear as early as June 1987. The records also show that the Veteran reported experiencing constant, severe head noises (tinnitus) as early as March 1996. Those records also show significant post-service occupational noise exposure, notably with the use of hearing protection. The Veteran has been afforded two VA audiological examinations in connection with his hearing loss and tinnitus claims. The January 2009 VA examiner opined that the Veteran's hearing loss and tinnitus were not caused by noise exposure in service. In support of the opinion, the examiner explained that the Veteran's service treatment records showed a preexisting hearing loss in the left ear and normal hearing in the right ear upon entrance into service. Furthermore, employment records showed hearing loss in 1982 in the left ear that was not significantly worse than his induction hearing test in 1966. Therefore, since the evidence did not show a significant change in left ear hearing from 1966 to 1982, there was no reason to conclude a change in hearing occurred in the right ear during that same period. Moreover, the examiner noted that the Veteran's hearing loss became progressively worse from 1982 through 2008, with the greatest decrease in hearing in the mid-1990s. The examiner also found that the Veteran's hearing loss in 1982, particularly with respect to the left ear, was not consistent with the effects of noise exposure, but that subsequent findings supported that occupational noise exposure was detrimental to the Veteran's hearing. The examiner further found that since tinnitus is associated with nerve damage from hearing loss, and as evidence indicates that the Veteran's hearing loss significantly worsened after leaving service, the tinnitus most likely occurred after service. Finally, the examiner added that the Veteran did not recall having hearing problems or tinnitus in service. Conversely, the October 2012 VA examiner found that the Veteran's hearing loss is at least as likely as not caused by or a result of noise exposure in service. The examiner found that the Veteran's hearing loss did not preexist service based on a conclusion that the Veteran's induction audiogram did not show hearing loss. The examiner also noted that there was no separation audiogram of record, and therefore, it could not be determined if a threshold increase occurred during service. Nevertheless, the examiner noted the Veteran's report of hearing loss approximately 30 years prior with worsening since onset. The examiner further found that the Veteran's tinnitus is at least as likely as not secondary to hearing loss and caused by or a result of noise exposure in service. The examiner noted that the type of noise the Veteran was exposed to during service suggests acoustic trauma resulting in tinnitus. Considering the record as a whole, the Board finds that the evidence is in relative equipoise as to the timing and etiology of the Veteran's hearing loss. As the record stands, there is one positive opinion and one negative opinion. Both opinions were based on a review of the claims file, examination of the Veteran, and were supported by some degree of rationale. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). Furthermore, both opinions considered the Veteran's post-service history of occupational and recreational noise exposure. However, both opinions also contain deficiencies that lessen their probative value. For example, the January 2009 examiner relied on the Veteran's statements that he did not recall hearing loss in service. However, as discussed, the Veteran's service treatment records clearly show complaints and findings of hearing loss in both ears in service. In this regard, in finding that there was no reason to conclude a change in hearing occurred in the right ear from 1966 to 1982, the examiner did not account for the September 1967 audiogram showing right ear hearing loss for VA purposes. Moreover, while the January 2009 VA examiner's rationale addresses the impact of the Veteran's post-service occupational noise exposure on his current hearing loss, it does not adequately address the hearing loss that existed in service and post service prior to the worsening shown in the mid-1990s. Similar deficiencies can be found in the October 2012 VA examiner's rationale. For instance, the October 2012 examiner erroneously stated that the Veteran's pre-induction examination did not show hearing loss, despite pre-induction audiometric findings consistent with a left ear hearing loss for VA purposes. Given the foregoing deficiencies, the Board finds that neither opinion is particularly probative. Nevertheless, resolving all doubt in the Veteran's favor, the Board finds that the Veteran's right ear hearing loss was incurred during service and his preexisting left ear hearing loss was aggravated during service. Regarding the left ear, there is clear and unmistakable evidence that the Veteran had hearing loss prior to service, as shown by audiometric findings and impaired hearing noted during November 1966 pre-induction examination. Even so, the Board finds that the Veteran's left ear hearing loss underwent a permanent increase in severity during service. In this regard, despite evidence of preexisting left ear hearing loss during pre-induction examination, there is no indication that the Veteran was aware of or complained of left ear hearing loss at that time. However, service treatment records show that during service, the Veteran became aware of and complained of left ear hearing loss on multiple occasions, including just prior to his January 1969 separation examination. As no audiometric testing performed during the January 1969 separation examination, the degree of any threshold shift is unknown. However, the Board finds that the documented complaints of left ear hearing loss proximate to the January 1969 separation examination demonstrate an increase in severity. Absent a specific finding that the increased left ear hearing loss shown in service was due to the natural progression of the disease, aggravation is presumed. 38 C.F.R. § 3.306. Accordingly, service connection for left ear hearing loss is established. Next, regarding the right ear, the record establishes that the Veteran did not have right ear hearing loss upon entering service. The record also shows that he was exposed to significant noise while in service, and was shown to have right ear hearing loss for VA purposes during service. Moreover, just prior to his January 1969 separation examination, he requested that his "ears" be checked, and he reported a history of "ear, nose, and throat" trouble on his January 1969 separation examination. As no audiometric testing performed during the January 1969 separation examination, the presence or degree of any right ear hearing loss is unknown. However, post-service records document right ear hearing loss for VA purposes as early as September 1982. Given the balance of evidence, all reasonable doubt will be resolved in the Veteran's favor. As such, when applying the benefit of the doubt rule, the evidence establishes that the Veteran was exposed to hazardous noise during service, had documented right ear hearing loss in service, and he has had continuous symptomatology of hearing loss since that time. Although the evidence does not establish compensable hearing loss within one year after service, it does establish that the Veteran's right ear hearing loss disability is related to service. Service connection for right ear hearing loss is warranted. 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. Finally, regarding tinnitus, the October 2012 VA examiner opined that the Veteran's tinnitus is secondary to his bilateral hearing loss. That opinion is consistent with the January 2009 VA examiner's notation that tinnitus is associated with nerve damage from hearing loss. Accordingly, as the Board finds that the Veteran's right ear hearing loss was incurred in service and the left hear hearing loss was aggravated by service, service connection for tinnitus is warranted on a secondary basis. 38 C.F.R. § 3.310. B. Skin Disorder Here, the RO has conceded that the Veteran's service from June 1967 to January 1969 included service in Vietnam within the applicable time period under 38 C.F.R. § 3.307(a)(6). Additionally, service treatment records show that in January 1969, the Veteran signed a malaria debriefing form related to his service in Vietnam. As such, the Veteran is presumed to have been exposed to herbicides coincident with such service. However, as discussed below, the weight of the evidence does not establish a current diagnosis of chloracne or other acneform disease consistent with chloracne, or any other skin condition that is subject to presumptive service connection based on herbicide exposure, or is otherwise related to service. Service treatment records show that the Veteran reported a history of acne during a September 1967 flight physical. However, physical examination at that time revealed no skin abnormalities. In July 1968, the Veteran was seen for a rash affecting his thigh and buttocks. A diagnosis was offered of atopic dermatitis, and the Veteran was treated with an injection and topical cream. Subsequent service treatment records, including a January 1969 separation examination, are negative for complaints or clinical findings relating to any skin disorder. Post-service medical records show that during an October 2004 VA Agent Orange examination, the Veteran reported a 10-year history of crusty areas on the ears and dorsum of his bilateral hand. He reported that when he returned from Vietnam, he "lost all his tan." Since that time, he reported, he blisters when he gets in the sun. Physical examination revealed scaly papules on the hands and ears, and the examiner diagnosed actinic keratosis of the hands, ears, and left forearm. Subsequent VA treatment notes dated through September 2012 show periodic treatment for skin problems diagnosed as actinic keratosis, seborrheic keratosis, or keratoses generally. Significantly, however, no VA provider indicated that the Veteran's keratoses were related to service, to include as a result of herbicide exposure therein. The Veteran was afforded an initial VA skin examination in November 2005 during which he reported a history of blisters, including a history of a water blister on his right forearm in Vietnam. He again reported that when he returned from Vietnam, he lost all of his tan and, since that time, he blisters easily when he is in the sun. He further reported that, over the years, his skin had developed lesions requiring removal. His hands, arms, and the tops of his ears were particularly affected and his symptoms had worsened over the last 10 years. Physical examination revealed crusty areas on the ears and dorsum of the hands. Following a review of service and VA treatment records, the examiner diagnosed history of actinic keratosis and seborrheic keratosis with recent removal of lesions and no sign of infection. The examiner noted the Veteran to be at high risk for recurrence due to his fair skin and sun exposure. The examiner further found that the Veteran did not have any symptoms consistent with chloracne due to Agent Orange exposure. However, the examiner did not offer an opinion as to the etiology of the Veteran's keratosis diagnoses. The Veteran was afforded a second VA skin examination in October 2012. The examiner noted a history of recurring crusty and flaky lesions affecting the Veteran's ears, face, and dorsum of his hands. The Veteran related his past diagnoses of actinic and seborrheic keratosis, and that he was at high risk of recurrence due to his fair skin and history of sun exposure. He indicated that currently, the actinic keratosis comes and goes and does not require treatment, though he had been treated in the past. The examiner noted many keratoses on the backs of the Veteran's hands, and one keratosis on top of his right ear. Following physical examination and a review of the claims file, the examiner opined that the Veteran's keratosis is less likely as not incurred in or related to any injury, event, or illness in service. The examiner noted that actinic keratoses are benign neoplasms and are found on skin that has been in the sun for a long period of time. The examiner noted that they are very common, especially during middle age and older. In this regard, the examiner noted that the sun is the major risk factor for developing actinic keratoses, and that the Veteran reported working outdoors for the highway department for 35 years. The examiner further acknowledged the references to acne and atopic dermatitis in service, but noted that there was no medical literature to support any link between those diagnoses and the Veteran's actinic keratoses. Furthermore, the examiner noted that Agent Orange exposure is not a risk factor for developing actinic keratosis. The examiner did not diagnose chloracne or any other acneform disease consistent with chloracne. Accordingly, the medical evidence of record does not establish a current diagnosis of chloracne or other acneform disease consistent with chloracne, or any other skin condition that is subject to presumptive service connection based on herbicide exposure. See 38 C.F.R. §§ 3.307, 3.309. While the Veteran asserted that he had chloracne in his June 2005 claim, this is not established by the medical evidence of record, and he is not competent (as a lay witness) to diagnose his particular skin disorder. Rather, this question requires specialized knowledge, training, or experience, due to the complex nature of the involved bodily system. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues). C.f. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (distinguishing situations in which a layperson is competent to identify the medical condition). Moreover, the Veteran subsequently acknowledged during his August 2011 Board hearing that he has not actually been diagnosed with chloracne. Additionally, the medical evidence of record does not establish a direct connection between the currently diagnosed skin disorders and service, to include herbicide exposure. As discussed above, the most recent VA examiner opined that the Veteran's current skin conditions are common, particularly with aging, and are due to sun exposure. The examiner found that they are not related to any incident or treatment for a skin condition during service, or to herbicide exposure. That October 2012 opinion provided an adequate rationale that was based on a review of treatment records, the Veteran's account of symptomatology and treatment, physical examination, current diagnoses, as well as medical literature and expertise. Accordingly, the Board affords it significant probative value. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). Significantly, there is no contrary medical evidence of record. The Board acknowledges that the Veteran has asserted in written statements and in testimony before the Board, that his current skin disorders are related to service, and specifically to herbicide exposure. However, an opinion as to the etiology of a skin disorder is a complex medical question for which lay testimony is not competent evidence. Accordingly, his assertion as to causation is neither competent nor probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Furthermore, to the extent that the Veteran asserts that his currently-diagnosed skin disorder has been recurring since service, the Board finds the Veteran's assertions not credible, notwithstanding the fact that service connection cannot be established based on continuity of symptomatology for the Veteran's diagnosed skin disorders. In this regard, the Veteran's skin conditions in service differ from his current skin conditions, and the skin condition in service affected different parts of his body than his current skin disorders. Moreover, while the Veteran has more recently indicated that his skin symptoms have been recurring since service, he initially reported only a 10-year history of his keratosis symptoms during his October 2004 Agent Orange examination. That initial report was made in furtherance of treatment and prior to the Veteran's June 2005 initial skin service connection claim. Accordingly, it is afforded more probative weight than his subsequent statements made in conjunction with his claim for benefits. The foregoing notwithstanding, there continues to be no medical opinion relating the Veteran's current skin disorders to his period of active service. Thus, even if the Veteran's assertions of in-service and post-service symptomatology are true, the assertions do not substantiate his claim for service connection for his currently-diagnosed skin disorders. As previously noted, the Veteran is not competent to create the requisite nexus between his current disorders and service. In summary, the preponderance of the evidence is against service connection for a skin disorder, to include as due to herbicide exposure. As such, the benefit of the doubt doctrine does not apply and the claim must be denied. 38 C.F.R. § 3.102. ORDER Service connection for bilateral hearing loss is granted. Service connection for tinnitus is granted. Service connection for a skin disorder is denied. ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs