Citation Nr: 1327482 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 10-04 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for a respiratory disability, claimed as a lung condition. WITNESSES AT HEARING ON APPEAL The appellant and his spouse ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from March 1966 to March 1968. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2008 rating decision by the Indianapolis, Indiana Regional Office (RO) of the United States Department of Veterans Affairs (VA). In that decision the RO denied the Veteran's request to reopen a previously denied claim for service connection for a lung condition. In April 2012 the Veteran had a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). The claims file contains a transcript of the hearing. In October 2012 the Board granted reopening of the claim for service connection for a respiratory disability, claimed as a lung condition. The Board remanded the reopened claim for the development of additional evidence. In March 2013 the Board again remanded the claim for the development of additional evidence. The Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. FINDINGS OF FACT 1. No respiratory disability was found on the Veteran's service entrance examination. 2. Cough and other respiratory symptoms treated in service resolved in service without residual chronic or recurrent pathology. 3. Right hemidiaphragm paralysis seen on imaging in 2008 was not seen on imaging in 2005 and was not present during service. CONCLUSIONS OF LAW 1. It is presumed that the Veteran's lungs and respiratory system were in sound condition when he entered service. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2012). 2. Current respiratory disability, including right hemidiaphragm paralysis, was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Respiratory Disability The Veteran essentially contends that he has a lung or respiratory disability that began during his service or was aggravated during his service. Service connection may be established 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. Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). The United States Court of Appeals for Veterans Claims (Court) has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative means of establishing service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran completed a medical history report in November 1965, before he entered service. He checked yes for a history of dizziness or fainting spells. He related a history of pneumonia affecting his left lung. On the report of a November 1965 medical examination of the Veteran for entrance into service, the examiner checked normal for the condition of the Veteran's lungs and chest. The examiner indicated that a November 1965 chest x-ray was negative. In April 1966 the Veteran sought outpatient treatment, complaining of a cough. He reported that a year earlier he was hospitalized with pneumonia affecting his left lung. He stated that for the past several months he had had a chronic productive cough. He indicated that he was a smoker. The treating clinician noted moist crackling in both lungs. The clinician indicated that the history the Veteran reported raised a question of bronchiectasis. In February 1967 the Veteran had outpatient treatment for coughing and chills, without fever. In February 1968 the Veteran had an examination for separation from service. In a medical history the Veteran again reported a history of hospital treatment for pneumonia affecting his left lung. The report of a February 1968 chest x-ray indicates that the x-ray showed a normal chest. On the examination report the examiner checked normal for the condition of the Veteran's lungs and chest, providing evidence against this claim. The claims file does not contain any records of post-service treatment of the Veteran in the remainder of the 1960s or in the 1970s or 1980s. In recent statements the Veteran has indicated that from soon after service he received private medical treatment. He stated that from the 1970s he received some of his treatment at VA facilities, and that more recently he has received more VA treatment. The Veteran reported that it is not possible to obtain records of the private treatment he received over the years directly following service. The claims file contains records of VA medical treatment. Over the course of the appeal and the Board remands, VA sought and obtained some additional and earlier records, but was unable to obtain any VA medical records from the 1960s, 70s, or 80s. The claims file contains records (in paper and electronic forms) of VA medical treatment of the Veteran from 1995 through 2013. Treatment included treatment for diabetes mellitus. Records show tracking from 1995 through 2012 of factors such as blood pressure, weight, and test results relevant to diabetes. A primary care clinician noted seeing the Veteran in May 1996. From at least as early as 1996 VA supplied medications. In a March 1999 visit for treatment of diabetes, the Veteran's lungs were clear to auscultation. In July 1999 the Veteran switched to a different VA facility for outpatient treatment. He reported a history of diabetes mellitus, high blood pressure, and hypercholesterolemia. He denied smoking. The treating clinician found that the Veteran's lungs had good air entry bilaterally, and indicated that he heard no added sounds, providing more evidence against this claim. In VA treatment visits one to three times a year in 2000 through 2003 clinicians followed the Veteran for disorders including diabetes, hypertension, hyperlipidemia, and hypercholesterolemia. In those visits the Veteran did not report respiratory problems. When asked, he denied dyspnea, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), reduced exercise tolerance, chest pain, cough, sputum production, wheezing, or cyanosis, providing factual evidence against his own claim. Throughout those visits clinicians reported that the Veteran's lungs sounded clear. In VA treatment in September 2004 the Veteran complained of exertional dyspnea, which he perceived as a little worse than before. He denied any chest pain. The treating clinician found that the Veteran's lungs were clear. In VA treatment in March 2005 the Veteran continued to complain of occasional shortness of breath at rest. He denied any cough, wheezing, sputum production, cyanosis, chest pain, orthopnea, paroxysmal nocturnal dyspnea, or exertional dyspnea. The treating clinician found that the Veteran's lungs were clear. In June 2005 the Veteran filed a claim for service connection and VA disability compensation for lung problems. He reported that he came down with lung problems in 1967, during his active service. He stated that a doctor tried to give him a separation with medical discharge and that he declined. He reported that presently doctors told him that he had problems affecting his left lung. He indicated that his lung condition had worsened as he got older. In statements submitted in September and October 2005 the Veteran reported that during his service in the 1960s a doctor told him that a left lung disorder, with "three bags of pus" on his left lung. He stated that the doctor told him that he could get out of service as a result. The Veteran indicated that after a telephone conversation with his father he chose to remain in service. He reported that during service he twice received orders to serve in Vietnam, but was never sent there. He expressed the belief that his lung condition was the reason that he was not sent there. A VA chest x-ray taken in October 2005 showed no focal airspace disease, pleural effusion, or acute cardiopulmonary disease. In a November 2005 rating decision the RO denied service connection for a lung condition. VA treatment records from 2006 and 2007 reflect the Veteran's reports that in May 2006 he was in an accident in which he sustained injuries of both shoulders. He reported having had surgeries on both shoulders in late 2006. In VA treatment in September 2007 the Veteran reported cold symptoms manifested by nasal congestion, rhinorrhea, and a cough productive of slightly purulent material. The treating clinician found that the Veteran's lungs were clear to auscultation. The clinician listed an assessment of upper respiratory infection and prescribed a course of an antibiotic. In September 2007 the Veteran again requested service connection for a left lung disorder. He reported that during service he became ill. He indicated that he learned that he had a left lung disorder when a service doctor told him. He again related that a doctor told him that he could get a medical discharge but that after consultation with his family he decided to remain in service. In a February 2008 statement the Veteran asserted that he was fine until he entered service. He reported that he never knew he had left lung trouble until during service, when a doctor told him so. He stated that the doctor indicated that he might not have trouble at that time but that he would in the future. He related that he smoked very, very little when he was in service, and never smoked after service. He reported that other doctors have told him that his left lung is weak. He stated that he perceived left lung weakness when he walked. In VA treatment in February 2008 the Veteran reported having been in a motor vehicle accident in which he was rear ended and suffered whiplash. The history of shoulder injuries and surgeries was also noted. In VA primary care in April 2008 the Veteran's chest was clear to auscultation. In a July 2008 statement the Veteran indicated that he was in good health when he entered service. He again stated that during service a doctor told him that he had a bad left lung problem and that he could obtain a medical discharge. In VA treatment in August 2008 the Veteran reported having a cold and coughing up sputum. He also reported that he tripped and fell recently and wondered if he had broken any ribs. Thoracic fluoroscopy showed a small amount of movement of the right diaphragm and paradoxical movement of the right hemidiaphragm. A radiologist provided the impression of right hemidiaphragm pheresis/paralysis. In an October 2008 VA pulmonary consultation the Veteran reported a history of right lung empyema in the 1960s. He reported a history of traumatic injury to both shoulders and surgical bilateral shoulder replacement in 2006. The consulting physician noted that a 2005 chest x-ray showed normal hemidiaphragms, while a more recent fluoroscopic examination showed a paralyzed right hemidiaphragm. The Veteran denied shortness of breath, dyspnea on exertion, or chest pain. He reported an intermittent, nonproductive cough left over from a recent cold. He also reported feeling a lump in his throat. The physician found that the Veteran's lungs were clear to auscultation, with no breath sounds heard in the right base. The physician's assessment was right sided hemidiaphragm elevation, suspected to be due to trauma with the shoulder injuries and subsequent surgeries (post-service). The physician indicated that further evaluation was needed regarding the lump in the throat, which could be related to the diaphragm or to reflux disease. Notes of VA treatment in November 2008 reflect a history of a fall onto the right side of the chest. A chest CT showed a 4.6 millimeter nodule in the right lower lobe, stable right hemidiaphragmatic elevation, and no evidence of mediastinal mass. In January 2009 the Veteran had a VA pulmonary consultation for evaluation of an elevated hemidiaphragm. It was noted that a 2005 chest x-ray showed normal hemidiaphragms, and that a recent examination showed a paralyzed right diaphragm. The Veteran denied shortness of breath, dyspnea on exertion, or chest pain. The clinician indicated that the diaphragm disorder could be related to traumatic injury that included injury of the shoulders. From 2009 forward VA treatment records included a diaphragm disorder in lists of the Veteran's problems. A follow-up chest CT in November 2009 showed linear airspace opacity in the right middle and lower and left lower lobes, described as likely representing subsegmental atelectasis versus scarring. The imaging showed calcified right upper lobe granuloma. The previous right lower lobe nodule had resolved. The right hemidiaphragm was elevated with likely eventration. There was no pleural effusion or pneumothorax. In VA treatment in November 2009 the Veteran's lungs were clear to anterior and posterior auscultation, without wheezes, rales, or rhonchi. The examiner noted that there was a question as to whether an elevated right hemidiaphragm was due to a truck accident and subsequent surgeries. In VA treatment in December 2009 the Veteran reported a history of falling on his chest earlier that year. In VA treatment records from 2010 forward lists of medications included Albuterol for breathing. In April 2010 the Veteran reported episodes of heart fluttering accompanied by shortness of breath. His lungs were clear to auscultation throughout, with no wheezes or crackles. A cardiologist indicated that the Veteran was having problems with congestive heart failure. On testing it was found that the Veteran had good exercise tolerance. In May 2010 the Veteran's lungs were clear to anterior and posterior auscultation without wheezes, rales, or rhonchi. In a May 2010 statement the Veteran reported that when he entered service he passed the physical examination and went through training. He stated that a doctor told him that he had a left lung problem and could get a medical discharge. He reported that the doctor told him that as he got older it would be harder for him to breathe. He indicated that when doctors listened to his lungs they listened to the left lung for a long time. He stated that he had experienced more difficulty breathing as he got older. In May 2010 the Veteran had a hearing at the RO before an RO Decision Review Officer (DRO). The Veteran reported that during service a doctor told him that he had problems with his lungs and could get a medical discharge. He stated that during service he struggled with demanding physical activities, and his breath would accelerate. He reported that he also had problems after service and that a physician found that the right side of his diaphragm was paralyzed. The Veteran's brother stated that the Veteran's breathing sounded raspy. The Veteran reported that presently he coughed a lot. The Veteran indicated that his duties in service were driving vehicles. He stated that after service he worked for railroads, in the insurance business, and driving a truck. In an August 2010 statement the Veteran asserted that he passed his physical to enter the service but developed lung problems while he was in service. In VA treatment in November 2010 the Veteran reported coughing and hacking that got worse at night. In VA treatment in June 2011 it was noted that the Veteran had shortness of breath due to a paralyzed diaphragm from a previous motor vehicle accident. In July 2011 the Veteran reported a two month history of coughing producing white phlegm. He reported feeling short of breath all the time. Chest x-rays showed that the right hemidiaphragm was stable compared to its appearance in an April 2010 x-ray. The lungs were grossly clear without focal consolidation, pneumothorax, or pleural effusion. The interpreting radiologist's impression was that no acute cardiopulmonary abnormality was identified. In the April 2012 Travel Board hearing the Veteran reported that before he entered service he was not aware of having any lung problems. He indicated that he was playing professional baseball when he was drafted for service. He reported that examinations and training while he was playing baseball did not reveal any lung problems. He stated that during service in 1966 a doctor told him that he had a problem with his lungs and could get a medical discharge. He reported that after his March 1968 separation from service he had diminished exercise capacity, dyspnea on exertion, and coughing. He stated that around May 1968 he started working for a railroad. He indicated that railroad doctors examined him and found a problem with his right lung. He stated that he then saw a doctor in Terre Haute, Indiana. He reported that around 1970 his coughing worsened. He indicated that for many years after service he had health insurance and did not go to any VA facility for health care. He stated that he first sought VA treatment probably in the early 1970s, in Indiana. He related that many doctors had listened to him breathing and stated that he had a problem. He indicated that eventually a doctor diagnosed paralysis of the right diaphragm. He stated that for the last several years he had used an inhaler and a nebulizer. In VA treatment in May 2012 the Veteran was noted to have disease of the diaphragm and to use Albuterol for breathing. On that visit the Veteran denied chest pain, shortness of breath, or cough. His lungs were clear to auscultation bilaterally with no wheezes, rales, or rhonchi. On VA examination in November 2012 the examining physician reported having examined the claims file. The examiner stated that the Veteran has right hemidiaphragm paralysis, and that the disorder was diagnosed in 2008. The examiner noted that the hemidiaphragm paralysis had occurred since a previous x-ray in 2005. The examiner indicated that the Veteran's disorder was treated with inhaled medications. Pulmonary function tests (PFTs) were performed in December 2012. The examiner provided the opinion that it is less likely than not that the Veteran's respiratory disorder was incurred in service. The examiner explained that the elevated hemidiaphragm had occurred since 2005, as documented by chest x-rays. In April 2013 the VA physician who examined the Veteran in November 2012 provided an addendum to the report of the November 2012 examination. The examiner again provided the opinion that it is less likely than not that the Veteran's respiratory disorder was incurred in service or caused by an event in service. The examiner provided rationale as follows: The veteran's current respiratory condition is hemidiaphragm paralysis, right-sided. This condition is easily seen on chest xray. This veteran was seen for a cough twice in 1966 and 1967. A chest xray in 1968 was normal. A chest xray in 2005 did not show hemidiaphragm paralysis. This condition developed between 2005-2008 and is likely unrelated to the veteran's in-service cough. It is important for the Veteran to understand that this evaluation is the most comprehensive review of this case by a medical provider and provides highly probative evidence against the Veteran's claim. In a July 2013 statement the Veteran asserted that original records from his service at Fort Hood should be obtained. He pointed out that before service he passed a physical when trying out for a professional baseball team, and that he passed the Army physical for entrance into service. He noted that his breathing problems began after he passed both of those physicals. The Board will consider whether the Veteran had a lung disorder when he entered service. In a medical history the Veteran completed in November 1965 prior to entry into service he reported that he had a history of pneumonia that affected his left lung. The service physician who examined the Veteran in November 1965 did not find, however, that as of November 1965 he had any ongoing abnormality of the lungs or chest, nor any disability affecting the lungs. There is no indication that the Veteran had any additional examination before he officially entered service in March 1966. In accordance with 38 U.S.C.A. § 1111, no lung disorder was noted on the entrance examination report, so no lung disorder was noted at entrance into service. Also in accordance with 38 U.S.C.A. § 1111, the Veteran is to be considered in sound condition at entrance into service unless clear and unmistakable evidence demonstrates that he had a disability that existed prior to service and was not aggravated by service. The November 1965 medical history, treatment notes from April 1966, and the February 1968 medical history each contain evidence that before entering service the Veteran received treatment for a respiratory disorder. The April 1966 treatment notes reflect the Veteran's report that his hospital treatment for pneumonia was about a year earlier, that for several months leading up to April 1966 he had a chronic productive cough, and that a clinician heard moist crackling in the lungs in April 1966. That report contains evidence that the Veteran had respiratory symptoms before service that continued into service. On the other hand, the clinician who examined the Veteran in November 1965 did not find any respiratory disability, and Veteran has asserted many times over the years that before service he was not aware of any respiratory problems. So while there is some evidence supporting the existence of a respiratory disorder before service, there is not clear and unmistakable evidence that the Veteran had a respiratory disability when he entered service. The absence of findings of respiratory disorder on the entrance and separation examinations tends to indicate that, despite respiratory symptoms during service, no respiratory disorder increased in disability during service. Having presumed that the Veteran's lungs and respiratory system were in sound condition when he entered service, the Board will consider whether a respiratory disorder was incurred in service, and whether a respiratory disorder found after service is attributable to any disease, injury, or other events in service. The Veteran has expressed concern that his service treatment records might have been destroyed in the 1973 fire at the National Personnel Records Center (NPRC) in St. Louis, Missouri. Fortunately, the Veteran's service treatment records exist. After the Veteran filed a VA benefits claim in 2005 the RO requested and received them. They include entrance and separation examination reports, outpatient treatment notes, and x-ray and laboratory reports. Personnel at the RO and at the Board have reviewed those records. The appear complete. The Veteran's service treatment records show that during service he received treatment for respiratory symptoms on two occasions, in April 1966 and February 1967. On the February 1968 separation examination the examiner did not find any respiratory disorder to be active at that time. In the course of pursuing his claim and appeal the Veteran has recounted events related to his respiratory system that are not reflected in the service treatment records. He reports that a military doctor came to him and told him that he had a lung disorder, and that this was when he first learned that he had a lung disorder. He states that the doctor "told him" that the lung disorder could be a basis for a medical discharge. He indicates that there was a telephone conversation involving the doctor, the Veteran, and the Veteran's parents. The Veteran relates that after speaking with his father he decided to decline the military discharge and continue in service. The Veteran has expressed frustration over the absence of existing records regarding the doctor's discussion of a possible medical discharge and the related telephone conversation. He has expressed considerable concern as to whether VA accepts as credible his accounts of those events. The Board concludes, however, that the occurrence of those events is not a matter that is central to whether the Veteran incurred in service a respiratory disorder that continued or recurred after service. Further, there is no indication that this conversation was ever put into writing. The critical question is whether the Veteran's current problem is the result of his service from many years ago. In February 1968, shortly before separation from service, the Veteran again reported a history of pneumonia. A clinician reviewed a February 1968 chest x-ray report, examined the Veteran, and determined that his lungs and chest were "normal". That direct medical evidence of normal lung condition just before separation from service is persuasive evidence that the Veteran did not have any respiratory disorder at the end of his service period. In recent statements the Veteran has stated that he perceived diminished respiratory capacity beginning soon after separation from service. However records of medical treatment many years after service, specifically those from the 1990s and the early 2000s, reflect that on most treatment visits the Veteran denied having respiratory symptoms, problems, or limitations, providing highly probative evidence against this own claim. In those records clinicians repeatedly found that the Veteran's lungs sounded clear. In treatment from 2004 forward the Veteran sometimes reported having some respiratory problems such as shortness of breath. He sustained traumatic upper body injuries in an accident in 2006. Based on imaging performed in 2008 he was found to have paralysis of the right side of his diaphragm. From 2010 forward he has been prescribed medication to assist with breathing. Many of these records associate the problem to the accident, not service, which only provides more evidence against this claim. In any event, whatever the cause, it is important for the Veteran to understand that his own prior statements disassociate his current problem with the problem he allegedly had in service. The Veteran has current respiratory disability and clinicians have provided a diagnosis of paralysis of the right side of the diaphragm. The evidence leaves some question as to the etiology of the current disorder, but medical treatment records reflect an absence of respiratory symptoms many years after service, and show recurrent or ongoing problems only beginning sometime after 2005. The 2012 and 2013 VA examination findings and opinions are from a qualified physician who reviewed the Veteran's records and explained his conclusions and opinions. That physician is competent to address medical causation and relationships, and his conclusions and opinions are persuasive. Considering the evidence regarding the condition of the Veteran's lungs and respiratory system at the end of service, and during periods after service, the Board concludes that the preponderance of the evidence is against incurrence of the current disability during service and is against a causal link between any events in service and the current disability. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The Court has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Also, in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that that the VLJ who conducts a Board hearing fulfill duties to (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. The RO provided the Veteran with VCAA notice in letters issued in August 2005 and January 2008. In those letters the RO addressed the information and evidence necessary to substantiate claims for service connection. The RO informed the Veteran how VA assigns disability ratings and effective dates. The letters also addressed who was to provide the evidence. In the April 2012 Travel Board hearing the undersigned VLJ fully explained the issues and suggested the submission of evidence that may have been overlooked. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. The Board therefore finds that, consistent with Bryant, the VLJ who conducted the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error provided in notice during the Veteran's hearing constitutes harmless error. The Veteran's claim file (including information on paper and in electronic form) contains service treatment records, records of post-service treatment and examinations, statements from the Veteran, and transcripts of the May 2010 DRO hearing and the April 2012 Travel Board hearing. The Veteran has had VA medical examination relevant to the claim on appeal. The examination was performed by a qualified clinician who reviewed the Veteran's claims file. The record includes the examiner's explanation of his findings and conclusions. The record thus contains examination findings that are adequate for the purpose of considering the claim on appeal. The VA Appeals Management Center (AMC) and the RO addressed the Board's 2012 and 2013 remand instructions by obtaining additional VA medical records, including records dated earlier than March 1999, by providing a VA medical examination, and by obtaining an addendum to the VA examination report with additional opinion and explanation. The Board is satisfied that there has been substantial compliance with the remand directives. Therefore no additional remand is needed, and the Board may proceed with review of the issues on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claim, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of his claim on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). ORDER Entitlement to service connection for a respiratory disability is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs