Citation Nr: 1322783 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 07-07 903 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from February 1971 to March 1974. The case was originally before the Board on appeal from a May 2005 rating decision of the Seattle, Washington Regional Office (RO) of the Department of Veterans Affairs (VA), which, in pertinent part, denied service connection for bilateral hearing loss and tinnitus, and denied an application to reopen a claim of service connection for a right knee disorder. The Fort Harrison, Montana RO now has jurisdiction of the Veteran's claims file. In March 2008 a videoconference hearing was held before the undersigned. A transcript of the hearing has been associated with the claims file. In April 2008, the Board remanded the case to the RO for additional development. In a July 2009 decision, the Board denied the Veteran's claims. He appealed the Board's decision regarding the denial of service connection for bilateral hearing loss and tinnitus to the United States Court of Appeals for Veterans Claims (Court). In a March 2010 Order, the Court vacated the Board's July 2009 decision as to those matters and remanded them to the Board for readjudication consistent with instructions outlined in a March 2010 Joint Motion for an Order Partially Vacating and Remanding the Board Decision and Incorporating the Terms of this Remand (Joint Motion) by the parties (VA Secretary and the Veteran). In September 2010, the Board remanded the case to the RO for additional development. Then, in January 2013, the Board requested a medical expert opinion from the Veterans Health Administration (VHA) pursuant to 38 C.F.R. § 20.901(a). That opinion has been received, and in April 2013 the Board sent the Veteran a copy of the opinion for his review and any response; the Veteran's representative responded with a written statement in June 2013. FINDINGS OF FACT 1. Bilateral hearing loss is not shown to have had its onset during service; sensorineural hearing loss (SNHL) was not manifested to a compensable degree within one year following the date of the veteran's separation from service; and a bilateral hearing loss disability is not shown to be related to an injury, disease, or event in service. 2. The veteran's tinnitus was not manifested in service, and is not shown to be related to an injury, disease, or event therein. CONCLUSIONS OF LAW 1. Service connection for bilateral hearing loss is not warranted. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 2. Service connection for tinnitus is not warranted. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. Under 38 U.S.C.A. § 5103(a), 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. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 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 VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post-adjudication VCAA notice by letters dated in January 2005, March 2006, and April 2008. The Veteran was notified of the evidence needed to substantiate claims of service connection for bilateral hearing loss and tinnitus; that VA would obtain service records, VA records and records of other Federal agencies; and that he could submit records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any non-Federal records on his behalf. The March 2006 and April 2008 notice included the elements of a service connection claim regarding the effective date of an award and the degree of disability. To the extent that two of the VCAA notice letters came after the initial adjudication of the claim in May 2005, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing defect, however, was cured because after the RO provided content-complying VCAA notice the claims were readjudicated as evidenced by the supplemental statement of the case, dated in May 2009 and February 2012. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). Furthermore, under 38 U.S.C.A. § 5103A, VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. As is noted above a videoconference hearing was held before the undersigned in March 2008. 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 Veterans Law Judge 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 Board hearing in March 2008, the Veterans Law Judge indicated that the hearing would focus on the issues of service connection for bilateral hearing loss and tinnitus (among other issues no longer on appeal), and discussed the elements of the claims that were lacking to substantiate the claims. The Veteran was assisted at the hearing by an accredited representative from The American Legion. The representative and the Veterans Law Judge asked questions to ascertain the nature and etiology of the hearing loss and tinnitus. There was no pertinent evidence identified by the Veteran or his representative that might have been overlooked and that might substantiate the claims. 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 claims. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The RO has also obtained the Veteran's service treatment records. The Veteran has submitted post-service occupational audiogram reports and a hearing evaluation report by Micken Hearing Services dated in January 2005. The Veteran has not identified any additional available evidence, such as VA outpatient records, that remains outstanding. VA has provided the Veteran with examinations to assist him to substantiate his claims. 38 U.S.C.A. § 5103A(d). He was examined by VA in April 2005 and February 2009, to determine the nature and etiology of his current bilateral hearing loss and tinnitus. Addendum reports dated in October 2010, August 2011, and January 2012 were received; however, as the examination reports were deemed to be inadequate to decide the claims, the Board in January 2013 arranged to have a VHA medical expert provide an opinion, which was received in March 2013. The Veteran was provided a copy of the opinion, and afforded opportunity to respond. As there is no indication of the existence of additional evidence to substantiate the claims, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. II. Legal Criteria, Factual Background, and Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Where a veteran served 90 days or more of continuous, active service and a chronic disease, such as SNHL (an organic disease of the nervous system), becomes manifest to a degree of 10 percent within one year from the date of separation from service, the disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in service. This may be accomplished by affirmatively showing inception during service. 38 C.F.R. § 3.303(a). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or 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. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence.). Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claims. The Veteran, who seeks service connection for bilateral hearing loss and tinnitus, served on active duty from March 1971 to March 1974. Service personnel records show that his military occupational specialty (MOS) was ammunition storage specialist, and that he served in Vietnam from August 1971 to April 1972. His service treatment records, including his February 1974 separation examination report, are silent for any complaints, findings, treatment, or diagnoses relating to hearing loss or tinnitus. Audiometry on a service entrance examination in March 1970 revealed that puretone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 N/A 0 LEFT 0 0 0 N/A 5 On a February 1974 separation examination audiometry puretone thresholds were: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 0 N/A 0 LEFT 25 15 0 N/A 0 Thus, on the basis of the service treatment records alone, the bilateral hearing loss (under VA standards for hearing loss disability) and tinnitus were not shown to have had onset during service, and service connection under 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a) is not established. Further, although service records show that the Veteran's military occupational specialty likely involved noise exposure of some level, there was no complaint or finding of hearing loss or tinnitus in service. It is also significant that at the time of the physical examination for separation, the Veteran specifically denied a history of ear trouble and hearing loss, and there was no hearing loss or tinnitus identified or diagnosed at that time. The Veteran is competent to describe bilateral hearing loss and tinnitus even though the symptoms were not recorded during service, but as the service treatment records lack the documentation of the combination of manifestations sufficient to identify the hearing loss and tinnitus, and sufficient observation to establish chronicity during service, and as chronicity in service is not adequately supported by the service treatment records, then a showing of continuity of symptomatology after service is required to support the claim. 38 C.F.R. § 3.303(b). As will be explained, there is not continuity of symptomatology after service to support either of the Veteran's claims. The Veteran was separated from active service in March 1974. It was 30 years after service when he initially filed a claim with VA in December 2004 for disability compensation for bilateral hearing loss and tinnitus. Medical records show that the initial documentation of a hearing loss disability (under VA standards) and tinnitus was in August 1998 (for hearing loss) and June 2001 (for tinnitus). Postservice records include reports of annual audiometric evaluations, dated from 1990 to 2007, from the Veteran's employer, General Services Administration (GSA), to assess any effects of occupational noise exposure. Audiometry since August 1998 shows elevated left ear puretone thresholds that suggested a hearing loss disability by VA standards, and audiometry since June 2001 shows elevated right ear puretone thresholds that suggested a hearing loss disability by VA standards. A June 2001 report notes a history of occasional ringing in the Veteran's ears. Therefore, as shown by the medical record, the initial documentation of hearing loss under VA standards for hearing loss disability and of tinnitus comes more than 24 years after the Veteran's discharge from service in March 1974. The absence of continuity of symptoms, from active service which ended in 1974 until 1998 (for hearing loss) and 2001 (for tinnitus), is persuasive evidence against continuity of symptomatology. Furthermore, it is also noted that the private annual hearing evaluations were conducted for the specific purpose of monitoring and assessing the Veteran's hearing condition for occupational health reasons. The audiogram reports are dated beginning in 1990 and available hearing histories were taken from 1998. The Veteran denied any ringing in the ears in 1998, and did not indicate any history of hearing loss or ringing in the ears when asked in 2000. In other words, when he had an opportunity to report a history of hearing loss or tinnitus after service (albeit many years after service at that point), the Veteran did not. It was not until after he filed his VA claim for disability benefits that he related having hearing loss and tinnitus symptoms over the years attributable to service. Moreover, on a private report from Micken Hearing Services in January 2005, it was noted that the Veteran reported noticing some hearing problems in the "past couple of years," so that even prior to receipt of his VA disability claim he did not relate a history of symptoms back to the time of service. Thus, based on the foregoing, the medical evidence does not show that there is continuity of symptomatology after service to support the claim. However, it is recognized that the Veteran is competent to describe symptoms of hearing loss and tinnitus during and after service. Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (Lay testimony is competent evidence insofar as it relates to symptoms of an injury or illness.). In statements and testimony, it does not appear that the Veteran has specifically claimed to experience hearing loss and tinnitus ever since service. Rather, he seems to have alleged ringing in his ears during service at the time of exposure to loud noises and then a gradual awareness of symptoms of hearing loss and ringing in the ears in the years leading up to the time he filed his VA disability claim. In any case, the absence of medical evidence of continuity of symptomatology combined with the objective finding on the separation examination of no hearing loss under VA standards for hearing disability and no ear disability, and the Veteran's own specific denial of history of ear trouble or hearing loss at separation outweigh any of his current statements that may imply continuity. This is so because the current statements lack credibility in light of the contemporaneous record during and after service. Stated another way, any assertions of hearing loss and tinnitus existing from the time of service, while competent, lack credibility both because they are self-serving and because they have been inconsistent, including with other evidence of record. Therefore, based on the Veteran's statements and medical records, there is no continuity of symptomatology to support the claims of service connection for bilateral hearing loss and tinnitus. As continuity of symptomatology has not been established, by the clinical record and by the statements of the Veteran, the preponderance of the evidence is against the claims of service connection for bilateral hearing loss and tinnitus based on continuity of symptomatology under 38 C.F.R. § 3.303(b). Further, such documentation of confirmed hearing loss under VA standards for hearing loss disability, coming more than 20 years after service separation, is well beyond the one year presumptive period for SNHL as a chronic disease (organic disease of the nervous system) under 38 U.S.C.A. § 1112 and 38 C.F.R. §§ 3.307 and 3.309. Hence, service connection for SNHL on a chronic disease presumptive basis is not established. The Board turns to the question of whether service connection for bilateral hearing loss and tinnitus may be granted on the basis that the disabilities were first diagnosed after service, considering all the evidence, including that pertinent to service under 38 C.F.R. § 3.303(d). The record contains statements by private and , VA examiners and a VHA consulting expert. In assessing the probative value of the medical opinions in the record, greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The probative value of a medical opinion is also generally based on the scope of the examination or review, as well as the relative merits of the analytical findings, and the probative weight of a medical opinion may be reduced if the physician fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In a private medical opinion, dated in January 2005, an audiologist at Micken Hearing Services opined that based on information obtained from the Veteran, "it is more likely than not the onset of his hearing loss and bilateral tinnitus is service connected." The report noted that the Veteran gave a history of exposure to loud sounds without ear protection during service, which included time spent as part of a demolition team that made and fired explosives. The Veteran also reported in-service noise exposure from small arms fire and trucks/fork lifts. He recalled occasions when his ears would ring when guns went off. Significantly, it was indicated that the Veteran did not recall having an "exit test" and that "no hearing tests had been found in his records [such is clearly incorrect]." The Veteran also reported some noise exposure from farm equipment and construction after service, when he did not always use ear protection, and he noted that he spent 18 years working for the federal government around equipment and machinery with required ear protection. It was noted that the Veteran complained of having hearing problems in the past couple of years. The Veteran also underwent VA examinations to determine the etiology of his bilateral hearing loss and tinnitus. On April 2005 VA examination, the diagnosis was mild bilateral sensory loss typical of a noise-induced etiology. The audiologist opined that the Veteran's "hearing loss and tinnitus were not caused by, or a result of his military service." He based his opinion in part on the audiometric examinations in service, which were interpreted as "normal." At the time of a February 2009 VA examination, the audiologist opined that "it is less likely than not that the onset of his bilateral hearing loss is related to his time in the service." The reasoning provided was that hearing was "normal" at entrance and exit in service. The audiologist further opined that as there was no shift in hearing thresholds during his military service, "it is less likely than not that the onset of his bilateral tinnitus is related to his time in the service" and "it is at least as likely as not that his tinnitus is related to his current hearing loss." Subsequently, clarifying medical opinions were sought and obtained because the VA examiners did not comment on the significance of the Veteran's 25 decibel puretone threshold at 500 Hertz in his left ear at the time of service separation, nor did they comment on the differences shown between the Veteran's enlistment and separation audiograms. In an October 2010 opinion, the VA examiner opined that the difference between the enlistment and separation audiograms was the result of test/retest error, as numerous subsequent hearing tests did not confirm apparent hearing loss in the 500 Hertz range that was noted on the separation audiogram. Further, there was no hearing loss in the 4000 Hertz range, which was the pattern for noise-induced hearing loss. Therefore, the examiner found that the Veteran did not suffer hearing loss as a result of noise exposure in service. In a January 2012 addendum to the earlier opinion given in February 2009, the VA audiologist observed that a shift in low frequency hearing loss was typically not associated with noise exposure and usually was related to a medical component (that is, a conductive hearing loss). Given that the Veteran had normal hearing in the high frequencies during service, the audiologist stated that there was no change from the opinion given in February 2009. Thereafter, the Veteran's representative argued in November 2012 that the VA examiner did not describe what medical condition the Veteran may have had to explain the low frequency hearing loss seen as a result of an increase in threshold levels on the service separation audiogram, suggesting that low frequency hearing loss and tinnitus were two signs of Meniere's disease as well as an indication of coronary artery disease (he submitted a copy of a medical article obtained via the internet to support his claim). In view of the unresolved issues presented in this case, the opposing medical opinions, and the opinions that had consistent conclusions but conflicting rationale, the Board in January 2013 sought a VHA medical expert opinion to reconcile the differences and provide clarification. In the opinion request, the Board asked the VHA examiner to review the record and furnish an opinion with rationale as to (1) whether it is at least as likely as not (a 50 percent or better probability) that the Veteran's current bilateral hearing loss and tinnitus were etiologically related to his period of service, to include exposure to noise trauma therein, and (2) whether there was sufficient evidence to discern that the current bilateral hearing loss and tinnitus were manifestations of a medical condition not noted by any of the previous examiners of record (as suggested by his representative in a November 2012 statement and as alluded to by a VA examiner in January 2012). The VHA examiner was also asked to comment on the allegation (with citation to internet article) that the low frequency puretone threshold increase at separation and alleged tinnitus reflect unrecognized/undiagnosed Meniere's disease or coronary artery disease. In March 2013, VHA experts (an audiologist and a Chief of Audiology) responded that the low frequency hearing thresholds measured at the time of the separation audiogram in 1974 were "not an accurate representation of the veteran's hearing sensitivity and were due to test/retest variability or even inaccurate results due to tester error." They explained with rationale that compared hearing thresholds obtained from a series of occupational audiograms after service with that of the separation audiogram, noting that more than a dozen audiograms available for review showed hearing thresholds that were less than the thresholds recorded at separation in 1974. In other words, the hearing thresholds at low frequency after service were "not significantly different from the thresholds recorded at enlistment." They opined that a persistent low frequency hearing loss, if present, would have appeared again in the years following 1974; they also found that there was no evidence of a permanent hearing threshold shift or conductive hearing loss at the low frequency. They noted that in an earlier report a VA examiner suggested that a hearing threshold shift at the low frequency of 500 Hertz may have been related to a conductive hearing loss; but they remarked that as there was no bone conduction threshold testing it could not be determined whether the suggested hearing threshold shift was conductive or sensorineural. Further, the VHA experts acknowledged that some research has shown a link between Meniere's disease or coronary artery disease on the one hand and persistent low frequency hearing loss on the other hand, but stated that there was no evidence that the Veteran currently had or has ever had persistent low frequency hearing loss for either ear. Finding that the Veteran's hearing thresholds were within normal limits throughout service and that there was no evidence of a permanent hearing threshold shift consistent with acoustic trauma due to noise exposure during service, the VHA examiners concluded that the Veteran's current hearing loss and tinnitus were less likely as not a result of noise exposure during service. As summarized above, several medical opinions of record pertain to the onset of the Veteran's bilateral hearing loss and tinnitus. In general, the opinions are unfavorable to the Veteran's claim, with the noted exception of the private opinion of January 2005 submitted by the Veteran. However, the VA examiners' opinions provided inconsistent rationale for the conclusions drawn or were otherwise inadequate, and the private opinion appears to have been based not on a review of the claims file but on the Veteran's own reported medical history, which notably included inaccurate statements, such as there purportedly being no in-service hearing tests found, when in fact there were audiological evaluation reports at enlistment and separation in the file. To reconcile the deficiencies and inconsistencies, a VHA opinion was sought. The VHA experts reviewed the Veteran's records, recorded his history, accounted for his history of noise exposures in and out of service, and provided a reasoned conclusion based on the facts gathered and their own medical expertise. Their conclusion was that the Veteran's bilateral hearing loss and tinnitus were not likely caused by or a result of military noise exposure. The Board finds that this opinion warrants substantial probative weight, particularly as it involved a careful review of the entire record and consideration of the degree of likelihood that the current conditions were related to in-service noise exposure, as claimed. Further, the opinion explained certain matters that were not clear in the previous opinions, to include the discrepancies in hearing thresholds at the lower frequency both during and after service, whether there was a hearing threshold shift or conductive hearing loss at the lower frequency during service, and whether hearing thresholds at separation were a manifestation of an unrecognized or undiagnosed condition such as Meniere's disease or coronary artery disease. The Veteran's own statements can be used only to provide a factual basis upon which a determination could be made that a particular injury occurred in service, not to provide a diagnosis or a medical opinion linking that in-service disease or injury to a current disability. Although he is competent to describe symptoms of hearing difficulty, see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of personal knowledge), hearing loss disability (as defined) is not a condition found under caselaw to be capable of lay observation, and the determination as to the presence of hearing loss therefore is medical in nature, that is, not capable of lay observation. See Savage v. Gober, 10 Vet. App. 488, 498 (1997) (On the question of whether the veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law , lay observation is competent); Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Also, under certain circumstances, a layperson is competent to identify a simple medical condition; or the layperson is reporting a contemporaneous medical diagnosis; or the 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). Although the Veteran is competent to describe symptoms of hearing loss, the diagnosis requires the application of medical expertise to the facts presented, which include the Veteran's history and symptomatology and audiometric testing as required under 38 C.F.R. § 3.385. For this reason, the Board determines that a hearing loss disability under 38 C.F.R. § 3.385 is not a simple medical condition that a layperson is competent to identify. On the other hand, tinnitus is a disability the presence of which (under caselaw) is within the capability of laypersons to observe. Charles v. Principi, 16 Vet. App. 370 (2002) (On the question of whether the veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent). Although the Veteran is competent to declare that he has tinnitus, to the extent his statement is offered as a lay opinion on causation, that is, an association between his tinnitus and service, a lay opinion is limited to inferences which are rationally based on the Veteran's perception and does not require specialized education, training, or experience to offer such diagnoses. As an opinion on causation in this case requires specialized education, training, or experience, and as no factual foundation has been established to show that the Veteran was qualified through education, training, or experience to offer such an opinion, his statement relating tinnitus to service is not competent evidence and is excluded, that is, the statement is not to be considered as evidence in support of the claim. Where, as here, the determinative question involves a nexus or causation where a lay assertion on medical causation is not competent evidence, competent medical evidence is required to substantiate the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or opinion. 38 C.F.R. § 3.159. As a layperson, the Veteran is not qualified through education, training, and expertise to offer a medical diagnosis or an opinion on medical causation. For these reasons, the Board rejects the Veteran's statements as competent evidence to substantiate that his current bilateral hearing loss either had onset during service or is related to an injury, disease, or event in service. The preponderance of the evidence is against the Veteran's claims of service connection for bilateral hearing loss and tinnitus, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER The appeal seeking service connection for bilateral hearing loss is denied. The appeal seeking service connection for tinnitus is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs