Citation Nr: 1324606 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 10-00 027 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for type II diabetes mellitus. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from December 1964 to June 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Regarding the Veteran's claim for a psychiatric disability, while the Veteran has claimed entitlement to service connection for "PTSD", there are other psychiatric diagnoses of record, such as depressive disorder. Given the Veteran's description of his claim for PTSD and the information of record, the Board finds that the claim encompasses any psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a Veteran's claim for service connection for PTSD may also include any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Therefore, the Board has characterized that portion of the appeal involving service connection for a psychiatric disability as encompassing any acquired psychiatric disorder, to include PTSD, as reflected on the title page. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. The Veteran has not, during the period pertinent to his August 2008 claim for service connection, had PTSD, and does not have any other psychiatric disability related to service. 2. The Veteran was not exposed to herbicides, including Agent Orange, in service, and his type II diabetes is not related to service in any other way. 3. The Veteran's bilateral hearing loss and tinnitus are directly related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304(f), 4.125 (2012). 2. The criteria for service connection for type II diabetes mellitus have not been met. 38 U.S.C.A. §§ 101(29)(A),1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 4. The criteria for service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for a 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 requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). 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. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as organic diseases of the nervous system and diabetes mellitus, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within a prescribed period following discharge from service; the presumptive period for arthritis is one year. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. §§ 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. A psychiatric disability, to include PTSD To establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The first requirement for service connection for PTSD is a medical diagnosis of the condition. Diagnoses of PTSD must be rendered in accordance with the diagnostic criteria for the condition set forth in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, his testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). See also 38 U.S.C.A. § 1154(b). If a veteran did not serve in combat, there must be independent evidence to corroborate a veteran's statement as to the occurrence of the claimed stressor. See Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). A veteran's testimony alone generally cannot establish the occurrence of a non-combat stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Also, during the course of the Veteran's appeal, the provisions relating to the establishment of service connection for PTSD, found at 38 C.F.R. § 3.304(f), were amended effective July 13, 2010. See 75 Fed. Reg. 39,843-39,852 (Jul. 13, 2010) and 75 Fed. Reg. 41,092 (Jul. 15, 2010) (effectuating a correction to the July 13, 2010 Federal Register). These amendments apply to any claim that "[w]as appealed to the Board before July 13, 2010 but has not been decided by the Board as of that date." Id. Here, because the Veteran's claim was appealed prior to July 13, 2010, but had not yet been decided at that juncture, the amended provisions of 38 C.F.R. § 3.304(f) are for consideration in this case. Specifically, 38 C.F.R. § 3.304(f) was amended to read that if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. In this case, the record does not reflect, and the Veteran has not contended, that either PTSD or any other psychiatric disability began in service. Service treatment records reflect no findings relating to PTSD or any other psychiatric disability. At the time of his June 1968 separation examination the Veteran was noted to have had a normal psychiatric evaluation. In June 1968, and again in April 1972, the Veteran reported not having had having never had depression, excessive worry, frequent trouble sleeping, or nervous trouble of any sort, providing factual evidence against his own claim at that time. Rather, as reflected in his December 2009 substantive appeal, the Veteran asserts that he currently has PTSD or another psychiatric disability related to stressful events he experienced during his period of service. He asserted in that statement that he has had multiple wives, numerous jobs, and emotional problems for 43 years. He also asserted that his in-service stressful events took place during his service on the USS Intrepid, and included helping to put the remains of an electrician in a body bag after he was crushed to death when he accidentally rode a bomb elevator from the hanger deck to the flight deck when it was closed, the carrier losing a rescue helicopter one night, and witnessing a man he did not know injured by a propeller. The earliest indication in the record of mental health problems is an August 2008 VA treatment record reflecting that the Veteran presented to be established, had concerns regarding PTSD, related a history of depression dating back 20 years (1988, which would be many years after service, providing more factual evidence against this claim), and reported recurrent nightmares, avoidance activity, and anxiety. In September 2008, a VA advanced nurse practitioner provided a mental health evaluation. At that time, the Veteran reported that in the 1990s he took Prozac and Zoloft, and that for the last two to three years he had been taking Cymbalta. He reported that his depression started in the 1990s (again, many years after service), and that he experienced some PTSD symptoms as a result of his service including nightmares, flashbacks, intrusive thoughts, avoidance of things reminding him of the trauma, and hypervigilance. He also reported depression symptoms including decreased sleep, decreased interest in things, low concentration and motivation, and nervous anxiety. The Veteran further reported working on a flight deck of an aircraft carrier in service loading bombs and rockets, seeing a man crushed, seeing a man fall overboard and drown, and being under machine gun fire when the machine guns on the ship would go off. PTSD screen was positive for combat trauma. The diagnosis was PTSD and recurrent, moderate depressive disorder. An October 2009 VA mental health outpatient note from a physician reflects that the Veteran endorsed some chronic PTSD-type symptoms, including a tendency to avoid crowded situations and long-standing difficulties with irritability. He related nightmares and being easily angered. The physician's diagnoses were depressive disorder, not otherwise specified, and PTSD per history. Importantly, this is not a finding of PTSD, but instead of finding of depression, which, by the Veteran's own statements, is indicated to have begun decades after service. The report of a March 2009 VA examination reflects that the Veteran's claims file was reviewed by the examining clinical psychologist, and that the Veteran was administered a clinical interview including a mental status examination and the Minnesota Multiphase Personality Inventory-II. The examiner noted that the Veteran had service in the Vietnam War and that there was a conceded stressor of witnessing a man going overboard, although it was noted that the Veteran indicated was not a very traumatic event for him. The Veteran reported that he noted depression in the late 1980s, initially noticing a feeling of doom and gloom, that he felt sad, irritable, and tired, and denied the emergence of this before the 1980s. When asked about PTSD symptoms he listed his traumatic experiences, but he did not report PTSD symptoms until asked about specific symptoms later in the examination. The Veteran reported that his claimed traumatic stressors all ran together, and that he could not identify exactly which cruise the events occurred on. He stated that there was one incident where he saw a man crushed because he was working on the bomb list and someone accidentally turned it on and it shot up to the upper deck. He reported seeing a man fall off the ship, but stated that they were able to rescue him and he did not describe a traumatic reaction to it. He did not mention the claimed issue of machine guns accidentally going off on planes on deck, although the examiner noted that this was noted in the record. He reported that he saw a man hit by an airplane propeller but not significantly injured. He also reported a helicopter crash that occurred at sea killing five people, but that he was not there for that and was not directly involved in the incident. On mental status examination, the Veteran's affect was somewhat blunted, but he did not show overt depression or anxiety, nor did he show significant emotion when discussing claimed stressors. The examiner stated that, in his opinion, the Veteran did not meet the criteria for PTSD, that he denied significant re-experiencing symptoms, and reported some mild avoidance symptoms but mainly relating to his depression, which was a separate issue in the examiner's opinion. The Veteran also reported some problems with sleep and anger, but did not endorse significant hypervigilance or exaggerated startle symptoms, and overall did not meet the full criteria for a PTSD diagnosis, though he did report some depression which emerged in the 1980s. Results of the Minnesota Multiphasic Personality Inventory-II were valid and did not indicate significant exaggeration or minimization of symptoms, and the Veteran showed results reflective of some anxiety, rumination, and worrisome neurotic personality, produced a PK scale raw score of 26 and T score of 80, which was reflective of some PTSD symptoms but was just below the acceptance cutoff score for a PTSD diagnosis. The examining psychologist's diagnosis was depressive disorder, not otherwise specified. The examiner noted that the depression emerged in the 1980s, well after the Veteran's discharge from the military, and that the examiner did not see a direct link between this and the Veteran's military service. The examiner stated that this appeared to have emerged mainly in the context of relationship difficulties he was having at the time. The examiner noted that the Veteran did report symptoms of PTSD, but did not meet the full DSM-IV criteria for this diagnosis in the examiner's opinion, providing highly probative evidence against the claim that the Veteran has PTSD. The Veteran also submitted records regarding his service on the USS Intrepid including a Letter of Commendation dated in January 1967, which reflects that the Veteran served on the Intrepid in the South China Sea from May to October 1966 and contributed to the execution of combat flight operations against insurgent forces, supply concentrations, and lines of communication in North and South Vietnam. A 1966 Command History of the USS Intrepid reflects that in June a man overboard was mistakenly reported and resulted in a helicopter crash killing three men and badly injuring another. Furthermore, a February 2009 PTSD worksheet of the RO indicates that the USS Intrepid and crewmembers played a significant role in combat operations in the South China Sea from May 1966 to October 1966, and that the Veteran's reported in-service stressors of seeing a man crushed, a man fall overboard, and experiencing machine guns go off while serving on the Intrepid were consistent with the circumstances of his service and should be conceded. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claim must be denied. Even assuming the validity of the Veteran's claimed in-service stressors, the weight of the competent and probative evidence suggests that the Veteran does not have PTSD, and does not have any other psychiatric disability related to service. The record reflects conflicting assessments of whether the Veteran has PTSD; the VA advanced nurse practitioner in September 2008 diagnosed PTSD, the VA physician in October 2009 found that the endorsed some chronic PTSD-type symptoms but diagnosed only "PTSD per history," and the March 2009 VA examiner opined that the Veteran did not have PTSD. The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In this case, the Board finds the March 2009 VA examiner's opinion to be the most probative evidence of whether the Veteran currently has PTSD. Unlike the VA advanced nurse practitioner in September 2008, the VA examining clinical psychologist was a mental health specialist, reviewed the entire claims file prior to making his determination, and conducted a more thorough examination of the Veteran, including psychological testing such as the Minnesota Multiphase Personality Inventory-II, which was reflective of some PTSD symptoms but was just below the acceptance cutoff score for a PTSD diagnosis. Furthermore, the March 2009 VA examiner provided a thorough explanation for his determination that the Veteran did not have PTSD, considering the DSM-IV criteria. The Board therefore finds the March 2009 VA examiner's opinion to be the most probative evidence of record regarding whether the Veteran has PTSD. As the weight of the evidence reflects that the Veteran did not have PTSD at the time of his August 2008 claim for service connection and has not had PTSD at any time since, there can be no valid service connection claim for that disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, No. 11-3272, 2013 WL 3455655 (Vet. App. July 10, 2013). Furthermore, while the competent and probative evidence reflects that the Veteran has current depressive disorder, it does not reflect that this disorder, nor any other psychiatric disability, is related to the Veteran's period of service. The only probative opinion regarding whether any psychiatric disorder, other than PTSD, might be related to the Veteran's period of service, is that of the March 2009 VA examiner, which was that such disorder emerged in the 1980s, well after his discharge from the military, mainly in the context of relationship difficulties he was having at the time, with no direct link to service. Again, the Board finds this opinion to be persuasive, as it was given by a clinical psychologist with appropriate expertise who reviewed the claims file, thoroughly examined the Veteran including with psychological testing, and provided a thorough rationale for his opinion. Moreover, there is no competent and probative opinion evidence of record indicating that depressive disorder or any other psychiatric disability other than PTSD is related to the Veteran's service, and neither the Veteran nor his representative have identified any such evidence. The Veteran's own statements suggest this problem began years after service, if not decades. The Board recognizes that the Veteran might believe that he has PTSD, or that his psychiatric problems are related to his period of service. Lay evidence can be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr, 21 Vet. App. at 308-09 (concerning varicose veins). Also, a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Jandreau, 492 F.3d 1372. However, a diagnosis of PTSD requires medical expertise. See 38 C.F.R. §§ 3.304(f), 4.125. As such, the Veteran is not competent to provide any such diagnosis and is clearly not qualified to diagnosis himself with PTSD related to the events in service. Moreover, to the extent that the Veteran might be competent at all to relate his psychiatric symptoms, including those of his depressive disorder, to his period of service, such an opinion is heavily outweighed by the objective medical opinion of the March 2009 VA examiner that, for the reasons discussed above, the Board finds persuasive in this case. Accordingly, the Board finds that the claim for service connection for a psychiatric disability, to include PTSD, must be denied. In reaching this conclusion, 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. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Type II diabetes mellitus Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all veterans who served in the Republic of Vietnam during the Vietnam Era (the period beginning on January 9, 1962, and ending on May 7, 1975). 38 U.S.C.A. § 1116(f) and 38 C.F.R. § 3.307(a)(6)(iii). Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). An opinion of the General Counsel for VA held that service on a deep-water naval vessel off the shores of Vietnam may not be considered "service in the Republic of Vietnam" for purposes of 38 U.S.C.A. § 101(29)(A), which defines the Vietnam era as the period beginning on February 28, 1961, and ending on May 7, 1975, and that this was not inconsistent with the definition of service in the Republic of Vietnam found in 38 C.F.R. § 3.307(a)(6)(iii). VAOPGCPREC 27-97 (July 23, 1997). Simply stated, a veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service to get the presumption. Id. Since issuance of that General Counsel opinion, VA has reiterated its position that service in deep-water naval vessels offshore of Vietnam (as opposed to service aboard vessels in inland waterways of Vietnam) is not included as "service in the Republic of Vietnam" for purposes of presumptive service connection for Agent Orange diseases. See comments section in Federal Register announcement of final rule adding diabetes to the list of Agent Orange presumptive diseases, 66 Fed. Reg. 23166 (May 8, 2001). Subsequently, in May 2008, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the interpretation by the Department of Veterans Affairs (VA) of the phrase "served in the Republic of Vietnam," which required the physical presence of a veteran within the land borders of Vietnam during service, was a permissible interpretation of 38 U.S.C.A. § 1116(a)(1)(A) and 38 C.F.R. § 3.307(a)(6)(iii). The United States Supreme Court, declined to review the case, and the decision of the Federal Circuit in Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008) is now final. The Secretary of VA revisited the issue in 2012 and determined, after review of a May 2011 Institute of Medicine (IOM) of the National Academy of Sciences report entitled "Blue Water Navy Vietnam Veterans and Agent Orange Exposure," that the evidence does not support establishing a presumption of exposure to herbicides for Blue Water Navy veterans. See Notice, 77 Fed. Reg. 247, 76170-76171 (2012). If a veteran was exposed to a herbicide agent (to include Agent Orange) during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, type II diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended beyond specific disorders, based upon extensive scientific research. See, e.g., 68 Fed. Reg. 27630-27641 (May 20, 2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (Nov. 2, 1999). Notwithstanding the presumption, service connection for a disability claimed as due to exposure to Agent Orange may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C.A. § 1113(b) and 1116 and 38 C.F.R. § 3.303. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claim for type II diabetes must be denied. The record does not reflect, and the Veteran has not contended, that type II diabetes began in service or within a year of service. Service treatment records reflect no findings pertinent to diabetes, and private treatment records reflect that type II diabetes mellitus was first diagnosed in May 2002, almost 34 years after the Veteran's separation from service. Thus, the presumptive service connection provisions for chronic diseases under 38 C.F.R. §§ 3.307 and 3.309(a) do not apply in this case. Rather, as reflected in his August 2008 claim and December 2009 substantive appeal, the Veteran asserts that he has type II diabetes mellitus as a result of exposure to Agent Orange in service. In the December 2009 substantive appeal, the Veteran argued that he did not know where his type II diabetes came from, and that it was not in his family history on either side. However, the evidence of record does not established that the Veteran was ever exposed to herbicides, including Agent Orange, in service. While the Veteran was awarded the Vietnam Campaign Medal with Device and the Vietnam Service Medal, service personnel records reflect that he served with the Attack Squadron Ninety-Five Ordnance Branch from November 1965 to June 1968, which included service aboard the aircraft carrier USS Intrepid in the South China Sea. The records do not reflect, and the Veteran has not asserted, that he ever had actual duty or visitation within the land borders of the Republic of Vietnam. Thus, the Veteran is not presumed to have been exposed to Agent Orange in service pursuant to 38 U.S.C.A. § 1116(f) and 38 C.F.R. § 3.307(a)(6)(iii). While service connection for type II diabetes may be established by showing that such disease was in fact causally linked to Agent Orange exposure, the only evidence of Agent Orange exposure provided by the Veteran is the bare assertion that his type II diabetes was the result of such exposure, and his assertion that he had no family history of type II diabetes. There are no further details of record of how the Veteran might have been exposed to Agent Orange, and neither the Veteran nor his representative has offered any or any indication of a problem that started in service, which is clearly not indicated. Therefore, the Board finds that the evidence does not support a finding that the Veteran was exposed to any herbicide including Agent Orange in service, and there is no other evidence indicating how the Veteran's type II diabetes might be related to service. Accordingly, the Board finds that the claim for service connection for type II diabetes must be denied. In reaching this conclusion, 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. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Bilateral hearing loss and tinnitus 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 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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 provisions of 38 C.F.R. § 3.385 do not require that hearing loss be shown as defined in that regulation at the time of separation from service, if there is sufficient evidence to demonstrate a relationship between the Veteran's service and his current disability. Hensley v. Brown, 5 Vet. App. 155 (1993). Service treatment records reflect that at the time of examination for entry into service in October 1964, on audiological testing, pure tone thresholds in the right ear, in decibels, were 5, 5, 5, 5, and 5 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively; pure tone thresholds in the left ear, in decibels, were 0, -5, -5, 0, and 5 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. They reflect no further audiometric findings during service, including at the time of his June 1968 separation from service; at that time whispered voice hearing test was noted to have been normal in both ears. Service examination in April 1972 also reflects no audiometric findings but normal whispered voice test in both ears; at that time, the Veteran reported that he had never worn a hearing aid and did not have and had never had ear trouble or hearing loss. Service personnel records reflect that the Veteran serviced as an Aviation Ordnanceman during service, including aboard the aircraft carrier USS Intrepid in support of combat operations in Vietnam. Information associated with the claims file by the RO indicates that Aviation Ordnancemen operate and handle aviation ordnance equipment, are responsible for the maintenance, of guns, bombs, torpedoes, rockets, and missiles, and that their duties include the stowing, issuing, and loading of munitions and small arms. On VA examination in March 2009, the Veteran complained of decreased hearing and tinnitus, and reported a history of military noise exposure from the flight deck and flight line. He reported that, subsequent to military service, he worked as a mechanic in an oil field and as a tool and dye maker in a machine shop. The Veteran also reported constant tinnitus, and that he did not know when his tinnitus had begun, but stated that it had been there as long as he could remember. On audiological testing, pure tone thresholds in the right ear, in decibels, were 15, 15, 25, 30, and 55 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively; pure tone thresholds in the left ear, in decibels, were 15, 15, 25, 45, and 75 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech discrimination scores using the Maryland CNC list were noted to be 100 percent in each ear. The diagnoses were bilateral sensorineural hearing loss and bilateral tinnitus. A March 2009 addendum from the March 2009 VA audiological examiner reflects that the claims file was reviewed and revealed that audiometric thresholds were within normal limits bilaterally at the time of the Veteran's enlistment and that "normal" whisper tests was recorded in 1968 at discharge from the military, but that no other information regarding the Veteran's hearing loss or any tinnitus was noted. The examiner stated that although the Veteran had a whisper test suggesting "normal" hearing at discharge, this test did not provide any frequency specific information. The examiner also stated that the Veteran had a positive history of occupational noise exposure as a mechanic in the oil field and as a tool and dye maker in a machine shop subsequent to his military service. The examiner concluded that, due to the lack of formal audiological testing at discharge and the Veteran's potential for significant occupational noise exposure subsequent to his military service, the examiner was unable to render an opinion regarding the Veteran's hearing loss and tinnitus without resorting to speculation. In his December 2009 substantive appeal, the Veteran asserted that, as an Ordnanceman, his flight operations station was on the fight deck and between the catapults or sometimes around behind the superstructure or the blast deflector, and that he had to be there during all launches and recoveries. He further stated that every hearing test he had ever taken starting in 1968 told him that he had hearing loss bad enough to wear hearing aids, and that, while he worked in an oil field as a mechanic, he worked there from 1982 to 1988, and his hearing loss had begun years before that. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claims for hearing loss and tinnitus must be granted. Given the Veteran's position as an Aviation Ordnanceman in service, including in support of combat operations in Vietnam aboard the aircraft carrier USS Intrepid, his descriptions of his in-service duties and assertions of very loud noise exposure in service are credible. Also, as reflected in the March 2009 VA examination report, the Veteran has both a current hearing loss disability for VA purposes, and a current tinnitus disability. Furthermore, the Board finds that the evidence regarding whether the Veteran's current bilateral hearing loss and tinnitus are related to his period of service is in relative equipoise. While neither hearing loss nor tinnitus was noted in service treatment records, including on June 1968 separation examination or April 1972 service examination, neither examination report includes any audiometric test results that might indicate whether the Veteran's hearing had worsened during service, and the Veteran at no time denied ringing in his ears; the only post-service audiometric test results are those noted in the March 2009 examination report. Moreover, the only competent and probative medical opinion is that of the March 2009 VA examiner, which was that the examiner was unable to render an opinion regarding the Veteran's hearing loss and tinnitus without resorting to speculation due to the lack of formal audiological testing at discharge and the Veteran's potential for significant occupational noise exposure subsequent to his military service. In this regard, while the Veteran's December 2009 statement that every hearing test he had ever taken starting in 1968 told him that he had hearing loss bad enough to wear hearing aids appears to be contradicted by the April 1972 report of medical history reflecting that he reported that he had never worn a hearing aid and did not have and had never had ear trouble or hearing loss, there is no evidence of record directly contradicting the Veteran's assertions that he noticed hearing loss and tinnitus prior to his post-service exposure to noise as an oil field mechanic. In light of the above, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's current bilateral hearing loss and tinnitus are related to his period of service. Accordingly, the claims for service connection for bilateral hearing loss and tinnitus must be granted. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letter dated in September 2008, which informed the Veteran of all the elements required by Pelegrini II and Dingess/Hartman. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA examination was not obtained for the service connection claim for type II diabetes because the evidence did not surpass the low threshold set by McLendon. Where the evidence does not establish that a disability may be associated with service, there is no need to obtain a medical opinion regarding any such nexus. As discussed above, the evidence does not establish that the Veteran was exposed to herbicides, including Agent Orange, in service, and there is no medical or other competent evidence suggesting a nexus between the Veteran's type II diabetes and service or any other such evidence that would warrant obtaining a medical nexus opinion. In this regard, the Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service (as in this case) would not suffice to meet the standards, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that the Veteran's claimed disability is related to military service is the conclusory generalized lay statements of the Veteran, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. The Veteran's service treatment records and other service records, VA medical treatment records, identified private treatment records and information regarding the Veteran's ship and claimed in-service stressors have been obtained. Also, the Veteran was provided a VA examination regarding his claimed psychiatric disability in March 2009. This examination and its associated report were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claim. As discussed above, the examination report was based on examination of the Veteran by an examiner with appropriate expertise who reviewed the claims file. 38 C.F.R. § 3.159(c)(4) (2012); Barr, 21 Vet. App. 303. Therefore, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a psychiatric disability, to include PTSD, is denied. Service connection for type II diabetes mellitus is denied. Service connection for bilateral hearing loss is granted. Service connection for tinnitus is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs