Citation Nr: 1322691 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 03-30 372 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for the cause of the Veteran's death. 2. Entitlement to Dependency and Indemnity Compensation under 38 U.S.C.A. § 1318 (West 2002). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on active duty from March 1970 to March 1974. The Veteran died in April 2000, and the appellant is his surviving spouse. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. FINDINGS OF FACT 1. A May 2000 certificate of death indicates that the Veteran was found dead at home in April 2000 at the age of 47. The certificate of death lists the immediate cause of death as complications from insulin dependent diabetes mellitus (IDDM) and chronic ethanol abuse. An autopsy was not performed. 2. At the time of his death, service connection was not in effect for any condition. 3. The Veteran had service in Vietnam during the Vietnam Era and was exposed to herbicides. 4. Diabetes mellitus and pancreatitis were not present in service and are not shown to be etiologically related to service. 5. Diabetes mellitus and pancreatitis were not manifested to a compensably disabling degree within the first year after the Veteran completed his active service. 6. There is affirmative evidence to the contrary showing that the Veteran's diabetes mellitus was not due to his exposure to herbicides in Vietnam. 7. The Veteran was not in receipt of or "entitled to receive" compensation for a service-connected disability that was rated by VA as totally disabling for a continuous period of at least 10 years immediately preceding death; or continuously since his release from active duty and for at least five years immediately preceding death. CONCLUSIONS OF LAW 1. A disability incurred in or aggravated by service or presumed to have been incurred in service did not cause or contribute substantially or materially to cause the Veteran's death. 38 U.S.C.A. §§ 1110, 1112, 1116, 1310, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2012). 2. The criteria for entitlement to Dependency and Indemnity Compensation under 38 U.S.C.A. § 1318, have not been met. 38 U.S.C.A. § 1318 (West 2002 & Supp. 2012); 38 C.F.R. § 3.22 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the appellant's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (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. 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. With regard to the appellant's claims for entitlement to service connection for the cause of the Veteran's death and entitlement to Dependency and Indemnity Compensation (DIC) under 38 U.S.C.A. § 1318, the appellant was provided a notification letters in July 2001, June 2005, June 2009, and May 2013 that satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006); Hupp v. Nicholson, 21 Vet. App. 342 (2007), rev'd on other grounds, Hupp v. Shinseki, 329 Fed. App. 277 (2009). The Board acknowledges that the June 2005, June 2009, and May 2013 letters were not sent prior to the initial adjudication of the claims; however, the claims were re-adjudicated by the June 2013 supplemental statement of the case. Therefore, any defect in the timing of the notice of this information was harmless. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (finding that VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). Further, the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). Next, VA has a duty to assist the appellant in the development of her claims. This duty includes assisting her in the procurement of service treatment records and other pertinent records, and providing a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The appellant's claims were previously before the Board in September 2012 and remanded at that time for additional evidentiary development, to include taking all procedurally appropriate actions to rebuild the evidence which was contained in the claims file, to include printing relevant documents that may have been stored on VA computers. The requested development was completed as directed and the appellant's claims are now before the Board for final appellate consideration. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In the present case, VA has made significant attempts to locate the Veteran's original claims file. An exhaustive search of the Records Management Center, the National Personnel Records Center, the Roanoke RO, the Lee's Summit RO, the St. Louis RO, the Milwaukee RO, and the Cleveland RO, was unsuccessful in locating the file. As the evidence indicated that the Veteran's original claims file was lost, a rebuilt claims file took its place. In attempting to reconstruct the original claims file, VA obtained the Veteran's service personnel records. VA repeatedly requested the Veteran's service treatment records, but responses from the National Personnel Records Center (NPRC) indicated that the records were lost with the original claims file, with the exception of a separation examination report, which has been associated with the rebuilt claims file. In a January 2012 memorandum, VA detailed its attempts to obtain the Veteran's service treatment records, concluding that the service treatment records were unavailable for review. In making a formal finding regarding the unavailability of these records, the RO noted that all efforts to obtain the information had been exhausted and that any further efforts to obtain the information would be futile. Remands from the Board dated from 2005 to 2012 also repeatedly informed the appellant that the Veteran's service treatment records were not in the file. In addition, VA requested all identified private medical treatment records not associated with the claims file. While Sentara Bayside Hospital records were procured, VA was informed that records from Virginia Beach Psychiatric Center were destroyed. The appellant was repeatedly informed the developments involving rebuilding the Veteran's claims file, to include the unavailability of identified private treatment records from Virginia Beach Psychiatric Center. In January 2013 and April 2013, initial and follow-up requests to the RO's listed above were sent, seeking that each provide any additional relevant documents that were in their possession. No additional documentation was received. VA treatment records from the VA Medical Center in Hampton, Virginia, were obtained and associated with the rebuilt file in May 2013. At that time, VA was also able to procure an old VETSNET printout, as well as records from the Hampton VA Medical Center to verify that the Veteran was "NSC," meaning that he had no service-connected disabilities during his lifetime. VA also contacted the appellant by letter in October 2012 and by phone in May 2013. She stated that she had no further information to submit and it was "fine" if the claim was "made ready for decision". Based on the foregoing, the necessary verifiable due diligence has been exercised in rebuilding the claims folder in the absence of success in locating the original claims folder. As part of the rebuilt claims folder, VA obtained the Veteran's service personnel records, available service treatment records, VA treatment records, and all available identified private treatment records. The appellant submitted private treatment records and written statements discussing her contentions, as well as provided testimony at an October 2003 RO hearing and an April 2005 Board videoconference hearing. Neither the appellant nor her representative has identified any outstanding pertinent evidence related to the claim for entitlement to service connection for the cause of the Veteran's death. The Board is cognizant that the appellant was not provided a VA medical opinion with respect to her cause of death claim. VA's duty to assist specifically includes providing a medical opinion when necessary if the claim at issue involves disability compensation. 38 U.S.C.A. § 5103A(d); 38 C.F.R. §§ 3.159(c)(4), 3.326. In the context of DIC claims, provision of a medical opinion or other medical analysis is pursuant to 38 U.S.C.A. § 5103A(a) rather than the above cited statute and regulations which pertain only to claims for disability compensation. DeLaRosa v. Peake, 515 F.3d 1319 (Fed. Cir. 2008); Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008). In this case, a medical opinion is not needed. There is no evidence of record, other that the appellant's assertions, that the Veteran's cause of death, diabetes mellitus, was related to service. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (finding no prejudicial error in Board's statement of reasons or bases regarding why a medical opinion was not warranted because there was no reasonable possibility that such an opinion could substantiate the Veteran's claim because there was no evidence, other than his own lay assertion, that reflected that he suffered an event, injury, or disease in service that may be associated with his symptoms). Moreover, there is no question that diabetes mellitus and pancreatitis had been diagnosed, but for reasons that will be more fully discussed on the merits below, there is no indication in the record of a causal connection between the Veteran's diagnosed disorders and service. See Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003) (noting that the Board has no obligation to obtain a medical opinion when there is no competent evidence that the appellant's disability or symptoms are associated with his service). Accordingly, it is not necessary to obtain a medical opinion in order to decide these claims. The available records and medical evidence have been obtained in order to make adequate determinations as to these claims. Hence, no further notice or assistance 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). Entitlement to Service Connection for Cause of Veteran's Death The appellant contends that complications of IDDM and chronic ethanol abuse, the immediate cause of death for her spouse, were caused by his military service. More specifically, she has asserted that presumed herbicide exposure during active service in Vietnam caused the Veteran to develop diabetes mellitus after service. In May 2001, the appellant filed a claim for entitlement to service connection for the cause of Veteran's death. In a February 2003 rating decision, the RO denied entitlement to service connection for the cause of Veteran's death. The appellant was notified of that decision and provided her appellate rights. She then perfected this appeal. Thereafter, the appellant's claim was remanded for additional evidentiary development in June 2005, May 2008, June 2010, and September 2012, and is now before the Board for final appellate consideration. When any veteran dies after December 31, 1956, from a service-connected or compensable disability, VA will pay dependency and indemnity compensation to such veteran's surviving spouse, children, and parents. 38 U.S.C.A. § 1310. In a claim where service connection was not established for the fatal disability prior to the death of the veteran, the initial inquiry is to determine whether the fatal disorder had been incurred in or aggravated by service. The Board must determine whether the fatal disorder should have been service-connected. 38 C.F.R. § 3.312. A service-connected disability is the principal cause of death when that disability, "singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto." 38 C.F.R. § 3.312(b). A service-connected disability will be considered as the contributory cause of death when that the disability contributed substantially or materially to death, combined to cause death, or aided assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. Service-connected diseases involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, with debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c). In order to be a contributory cause of death, it must be shown that there were "debilitating effects" due to a service-connected disability that made the veteran "materially less capable" of resisting the effects of the fatal disease or that a service-connected disability had "material influence in accelerating death," thereby contributing substantially or materially to the cause of death. Lathan v. Brown, 7 Vet. App. 359 (1995); 38 C.F.R. § 3.312(c)(1). Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. For certain chronic disorders, such as diabetes mellitus or endocrinopathies, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection on the basis of continuity of symptomatology can only be established for the chronic diseases as specified at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With chronic disease shown as such in service, or within the presumptive period, so as to permit a finding of service connection, 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), 3.307. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service, or in the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f). Moreover, VA regulations provide that, if a veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for certain disorders if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there was no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. Those disorders include Type 2 diabetes, also known as Type II diabetes mellitus or adult-onset diabetes. 38 C.F.R. § 3.309(e). Evidence which may be considered in rebuttal of service incurrence of a disease listed in § 3.309 will be any evidence of a nature usually accepted as competent to indicate the time of existence or inception of disease, and medical judgment will be exercised in making determinations relative to the effect of intercurrent injury or disease. The expression "affirmative evidence to the contrary" will not be taken to require a conclusive showing, but such showing as would, in sound medical reasoning and in consideration of all evidence of record, support a conclusion that the disease was not incurred in service. 38 C.F.R. § 3.307(d). The NPRC verified that the Veteran served in the Republic of Vietnam from November 21, 1972, to November 28, 1972, and from January 22, 1973, to January 26, 1973. As such, the Veteran's exposure to herbicides is presumed, absent affirmative evidence establishing a contrary finding. 38 C.F.R. § 3.307(a)(6)(iii). There exists no evidence to refute the Veteran's presumed exposure to herbicides. Therefore, the Board finds that the Veteran's exposure to herbicides is presumed. However, regulations governing presumptive service connection for Agent Orange do not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (1994). The Veteran's available service treatment records, specifically his March 1974 service separation examination report, are negative for any diagnosis or indication of diabetes mellitus or pancreatitis. Post-service private and VA treatment records dated from 1974 to 2000 showed numerous findings for insulin dependent diabetes mellitus (IDDM) and pancreatitis. Private inpatient treatment records from DePaul Hospital dated from April 1984 to May 1984 are associated with the record. The Veteran was admitted in April 1984, with an eight hour history of sudden onset of nausea and vomiting, which began after he stopped drinking alcohol the morning of his admission. The examining physician listed an impression of probable exacerbation of chronic pancreatitis, with high amylase, secondary to alcoholism, "but consider" pancreatic duct stone. An additional impression listed was hypoglycemia, secondary to alcohol. In the assessment section of a pulmonary medicine consultation, the examining physician noted that the Veteran's blood sugars had been high and that he was receiving insulin appropriately. A May 1984 VA hospital discharge summary listed multiple diagnoses, including pancreatitis, secondary to alcohol abuse. The Veteran's hyperglycemia, noted on admission, was indicated to resolve immediately following admission. The Veteran was noted to have no complications from hyperglycemia and receive no insulin. An additional May 1984 VA treatment record showed a problem list including hyperglycemia. It was noted that the Veteran's hyperglycemia should be followed since he may have severely damaged his pancreas. A July 1984 VA treatment note listed a diagnosis of hyperglycemia. An additional record that month showed the Veteran was given insulin. A July 1984 VA hospital discharge summary listed multiple diagnoses, including IDDM, probably secondary to history of pancreatitis. The Veteran was noted to have a history of pancreatitis secondary to alcohol (ETOH) abuse. It was again noted that the Veteran's hyperglycemia was felt to be secondary to his pancreatitis. In a February 1986 VA medical record, a VA treatment provider in the Diabetes Clinic noted that the Veteran had diabetes mellitus, secondary to pancreatitis in 1984. An additional provider also listed a provisional diagnosis that same month that IDDM was "questionably (?)" secondary to pancreatitis. A March 1986 VA treatment record noted a major improvement in glycemic control. Private inpatient treatment records from DePaul Hospital dated from May 1987 to June 1987, reported the Veteran's past medical history, to include a history of diabetes and history of ETOH abuse causing diabetes mellitus, with history of acute pancreatitis. A January 1988 VA hospital discharge summary listed multiple diagnoses, including IDDM, secondary to pancreatitis. The Veteran's past medical history was indicated to be notable for pancreatic endocrine insufficiency, secondary to acute alcoholic pancreatitis in 1984. A February 1988 VA hospital discharge summary listed diagnoses of chronic pancreatitis, active peptic ulcer, and uncontrolled diabetes mellitus, secondary to chronic pancreatitis. In February 1988, a VA treatment provider listed an assessment of pancreatitis, uncontrolled diabetes mellitus, and active peptic ulcer. The Veteran continued to complain of epigastric burning in March 1988. The examiner noted that the Veteran's diabetes mellitus was likely controlled and that the Veteran had chronic pancreatitis. In an April 1988 VA medical record, the Veteran reported having diabetes since 1982 and being on insulin. A March 1989 treatment record listed an assessment of diabetes mellitus control, with decreased sugars, secondary to increased activity. In a July 1989 VA abbreviated medical record, a VA physician noted a past medical history of IDDM of eight years, as well as ETOH abuse, with chronic pancreatitis. The physician indicated that pancreatitis was the etiology of IDDM. In January 1990, the Veteran's diabetes was listed as well controlled. Follow-up notes dated in September 1990 and October 1990 for adult onset diabetes mellitus (AODM) revealed the Veteran's insulin was decreased and he was fearful of hypoglycemia. A May 1991 follow-up note for AODM revealed the Veteran was adhering to his meal schedule. VA treatment notes dated in February 1994 reflected findings of AODM and notations concerning treatment for hypoglycemic reactions. An October 1995 treatment from M. D. C., M.D. showed an assessment of IDDM and a discussion of insulin adjustment. Private treatment notes from Sentara Bayside Hospital detailed that the Veteran was hospitalized in November 1999 for diabetic reaction, with a past medical history of IDDM. A March 2000 discharge summary indicated that the Veteran was brought in due to having seizures. He was noted to have a history of chronic alcoholism and was drinking again. A consultation report showed a past medical history of significant for chronic alcohol dependence, with multiple prior hospitalizations for related complications to include pancreatitis; and a long history of insulin dependent diabetes mellitus for more than 18 to 20 years. Discharge diagnoses were listed as alcohol intoxication and alcohol withdrawal, diabetes mellitus type II insulin treated, Korsakoff's psychosis, and seizures. The Veteran was found dead at home in April 2000 at the age of 47. The certificate of death lists the immediate cause of death as complications from insulin dependent diabetes mellitus and chronic ethanol abuse. An autopsy was not performed. At the time of the Veteran's death, service connection was not in effect for any disorder. In her March 2003 notice of disagreement, the appellant indicated that the Veteran's diagnosis of pancreatitis was not made before his diabetes mellitus diagnosis. In October 2003, the appellant submitted an internet article concerning hyperosmolar hyperglycemic nonketotic coma and a medical treatise excerpt about chronic pancreatitis. During her October 2003 RO hearing, the appellant's representative discussed the internet and treatise evidence that had been submitted, indicating that it was introduced to show how uncontrolled hyperglycemia could affect the pancreas. The appellant endorsed the Veteran's consumption of alcohol in varying levels over the years. Thereafter, the appellant indicated that the Veteran's first hospitalization at DePaul Hospital started with his complaints of stomach pain in April 1984. She indicated that the Veteran was then transferred to the VA hospital in Hampton, Virginia. On discharge, she reported the Veteran was informed he had diabetes. During her April 2005 videoconference hearing, the appellant indicated that the Veteran was not an alcoholic. She indicated that one of the Veteran's private physicians, Dr. C. told the Veteran that he could have been diabetic for years. The appellant reported her belief that alcoholism was not a major contribution to the Veteran's health and that the Veteran showed symptoms of diabetes like disorientation, bad eating habits, anger, and weakness far before he was diagnosed. The appellant highlighted that his diabetes treatment began in 1987, that diabetes mellitus was the Veteran's primary cause of death, that the Veteran was in Vietnam, and that diabetes mellitus was a presumptive disease under Agent Orange exposure. Service connection for the cause of the Veteran's death is not warranted. As an initial matter, there is no factual basis in the record that diabetes mellitus or pancreatitis were incurred during service, or manifested as a chronic disease within a year thereafter, or for several years after his discharge from service in 1974. Available service treatment records do not reflect findings of any endocrine or pancreatic disorder at military service discharge. Post-service medical evidence of record first showed findings of diabetes mellitus and pancreatitis many years after the Veteran's separation from active service. The passage of many years between discharge from active service and the continuity of symptomatology or medical documentation of a claimed disability are factors that tend to weigh against a claim for service connection. Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Evidence of record clearly reflects that diabetes mellitus and pancreatitis were not manifested to a compensably disabling degree within the first year after the Veteran completed his active service in 1974. Although the appellant testified that a physician had verbally told the Veteran that he could have been diabetic for years, this statement is speculative and therefore is of limited, if any, probative value. Bloom v. West, 12 Vet. App. 185, 186-87 (1999) (treating physician's opinion that veteran's time as a prisoner of war "could" have precipitated the initial development of his lung condition found too speculative). Significantly, the record does not include any medical evidence or opinion suggesting a causal relationship between the Veteran's fatal diabetes mellitus and chronic alcohol abuse or his diagnosed pancreatitis and his active military service, and neither the appellant nor her representative has identified or alluded to the existence of any such opinion. In fact, multiple private and VA treatment providers overwhelmingly indicated that the Veteran's diabetes mellitus was due to or secondary to pancreatitis and that pancreatitis was related to alcohol use. Those post-service findings also represent "affirmative evidence to the contrary" showing what would, in sound medical reasoning and in consideration of all evidence of record, support a conclusion that the Veteran's diabetes mellitus was not incurred in service, to include as secondary to presumed herbicide exposure. Thus, there is no basis upon which to conclude that the Veteran's immediate cause of death was incurred in or aggravated during military service, including on any presumptive basis. 38 C.F.R. §§ 3.303, 3.307, 3.309. In support of her claim, the appellant submitted an internet article and medical treatise excerpt about diabetes mellitus and pancreatitis. A medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998) (finding that medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus); Mattern v. West, 12 Vet. App. 222, 228 (1999). Here, the internet research and medical treatise materials associated with the file are of very little probative value, as they were general in nature, did not specifically relate to the facts and circumstances surrounding this particular case, and were not accompanied by the opinion of any medical expert. The appellant's statements that the cause of the Veteran's death was related to herbicide exposure during active service are not competent. Evidence of the etiology of the cause of the Veteran's death requires medical diagnosis based on diagnostic testing, which the appellant is not trained to perform. See Jandreau v. Nicholson, 492 F.3d at 1377 (holding that whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the United States Court of Appeals for Veterans Claims). The Board is cognizant that the appellant's statements are competent evidence as to observable symptomatology, including weakness, disorientation, anger, and bad eating habits. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions); Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable, symptoms of disability"). However, the statements that the Veteran's death was caused by a disability incurred during service draw medical conclusions which the appellant is not qualified to make. Although lay persons are competent to provide opinions on some medical issues, the etiology of the Veteran's cause of death falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Jandreau, 492 F.3d at 1377. Accordingly, service connection for the cause of Veteran's death is not warranted. The evidence of record simply does not establish either on a direct or presumptive basis that the Veteran's diabetes mellitus or pancreatitis was caused by his military service. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Entitlement to DIC under 38 U.S.C.A. § 1318 In pertinent part, 38 U.S.C.A. § 1318 authorizes payment of DIC to an eligible surviving spouse in cases where a veteran's death was not service connected, provided the veteran was in receipt of or "entitled to receive" compensation for a service-connected disability that was rated by VA as totally disabling (100 percent) (1) for a continuous period of at least 10 years immediately preceding death; or (2) continuously since the veteran's release from active duty and for at least five years immediately preceding death. See 38 C.F.R. § 3.22. As service connection was not awarded for any disorder during the Veteran's lifetime, the appellant does not meet the basic eligibility requirements for entitlement to DIC benefits under 38 U.S.C.A. § 1318 and the claim must be denied. ORDER Service connection for the cause of the Veteran's death is denied. DIC under the provisions of 38 U.S.C.A. § 1318 is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs