Citation Nr: 1328048 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 02-21 762 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for a neck disability with associated headaches. 3. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for a gastrointestinal disability. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1950 to August 10, 1954, and August 16, 1954, to September 1963. These matters initially came before the Board of Veterans' Appeals (Board) from an October 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In that decision, the RO denied the Veteran's petition to reopen claims of service connection for residuals of a right shoulder injury and residuals of a neck injury with headaches as new and material evidence had not been submitted and denied entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for a duodenal ulcer due to treatment in 1997 at the VA Medical Center in Oklahoma City, Oklahoma (VAMC Oklahoma City). In his December 2002 substantive appeal (VA Form 9), the Veteran requested a Board hearing. He subsequently withdrew his hearing request. In August 2004, the Board granted the Veteran's petition to reopen the claims of service connection for a right shoulder disability and a neck disability with headaches and remanded the underlying claims as well as the 1151 claim listed above for further development. In July 2006, the Board granted the Veteran's motion to advance this appeal on its docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). In August 2006, the Board denied the claims of service connection for a right shoulder disability and a neck disability with headaches and the claim for compensation under the provisions of 38 U.S.C.A. § 1151 for a gastrointestinal disability. The Veteran appealed the Board's denials to the United States Court of Appeals for Veterans Claims (Court). In an October 2008 memorandum decision, the Court set aside the Board's August 2006 decision and remanded the case for readjudication in compliance with directives specified in the Court's decision. In June 2009 and January 2011, the Board remanded these matters for further development in compliance with the Court's decision. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claims. The documents in this file have been reviewed and considered as part of this appeal. FINDINGS OF FACT 1. The Veteran's current right shoulder disability is the result of an in-service injury. 2. The Veteran's current neck disability with associated headaches is the result of an in-service injury. 3. The Veteran's current gastrointestinal disabilities were not caused by any VA hospital care or treatment in 1997, including his hospitalization at VAMC Oklahoma City. CONCLUSIONS OF LAW 1. The Veteran's current right shoulder disability was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). 2. The Veteran's current neck disability with associated headaches was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303. 3. The criteria for entitlement to benefits pursuant to 38 U.S.C.A § 1151 for a gastrointestinal disability have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). As the Board is granting the claims of service connection for a right shoulder disability and a neck disability with associated headaches, the claims are substantiated and there are no further VCAA duties as to these issues. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). With respect to the claim for compensation under the provisions of 38 U.S.C.A. § 1151 for a gastrointestinal disability, under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In letters dated in October 2004 and December 2005, the RO notified the Veteran of the evidence needed to substantiate his claim for compensation under the provisions of 38 U.S.C.A. § 1151 for a gastrointestinal disability. These letters also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claim, in a March 2006 letter. There was a timing deficiency in that the October 2004, December 2005, and March 2006 letters were sent after the initial adjudication of the Veteran's 1151 claim. This timing deficiency was cured by readjudication of the claim in an August 2010 supplemental statement of the case. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained all of the identified relevant post-service VA treatment records and private medical records. In addition, the Veteran was afforded VA examinations to determine the nature of any current gastrointestinal disability and to obtain opinions as to whether there was a relationship between any such disability and VA treatment. The agency of original jurisdiction (AOJ) has contacted the National Personnel Records Center (NPRC) on several occasions and requested all of the Veteran's available service treatment records. The NPRC responded that no such records were available and that they were presumed to have been destroyed in a fire at that facility in 1973. Destruction of service treatment records does not create a heightened benefit of the doubt, but only a heightened duty on the part of VA to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision. Cromer v. Nicholson, 19 Vet App 215 (2005); Russo v. Brown, 9 Vet. App. 46, 51 (1996). Where service treatment records are missing, VA also has a duty to search alternate sources of service records. Washington v. Nicholson, 19 Vet. App. 362 (2005). The service department has not suggested alternate sources of records, but VA did ask the Veteran for copies of any records in his possession and provided him with a Request for Information Needed to Reconstruct Medical Data form (NA Form 13055). In a June 1990 statement (VA Form 21-4138), the Veteran reported that he did not have any service treatment records in his possession. Thus, the Board finds that any further efforts to obtain the Veteran's service treatment records would be futile. 38 C.F.R. § 3.159(c)(2). Nevertheless, as the Veteran's current 1151 claim is based on VA medical treatment that occurred decades after his separation from service, any service treatment records would not be relevant in this instance. In its August 2004, June 2009, and January 2011 remands, the Board instructed the AOJ to, among other things, send the Veteran a sufficient VCAA notice letter (including notice pursuant to the Court's decision in Dingess), obtain all records pertaining to his treatment at VAMC Oklahoma City from October 31, 1997 to November 3, 1997, attempt to obtain all relevant treatment records from Dr. Serrano, and afford the Veteran VA examinations to assess the nature and etiology of his claimed gastrointestinal disability. As explained above, all available relevant VA treatment and private medical records have been obtained and associated with the claims file (including all available relevant treatment records from VAMC Oklahoma City dated from October 31, 1997 through November 3, 1997 and from Dr. Serrano). The Veteran was provided sufficient VCAA notice letters in October 2004, December 2005, and March 2006 and notice pursuant to the Court's decision in Dingess was provided in the March 2006 letter. Moreover, VA examinations were conducted in November 2004, May 2010, and October 2012 and opinions concerning the etiology of the Veteran's claimed gastrointestinal disability have been obtained. Hence, the AOJ substantially complied with all of the Board's relevant August 2004, June 2009, and January 2011 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the 1151 claim being decided herein. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis 1. Service Connection Claims Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities listed in 38 C.F.R. § 3.309(a), including arthritis, is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a chronic condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a) (2012). In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) 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); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between 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")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if such is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307(a), 3.309(a) (2012). Notwithstanding the foregoing presumption, a claimant is not precluded from establishing service connection with proof of direct causation. 38 U.S.C.A. § 1113(b) (West 2002); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, VA examination reports dated in October 2012 include diagnoses of degenerative joint disease of the right shoulder, a right shoulder strain, cervical degenerative disc disease/degenerative joint disease, and a cervical strain. Thus, current right shoulder and neck disabilities have been demonstrated. The Veteran contends that he injured his right shoulder and neck in service sometime between 1955 and 1957 when he was working under an aircraft wing and the wing collapsed. Right shoulder and neck symptoms have reportedly persisted ever since that time. The Veteran has not reported, and the evidence does otherwise indicate, that he has experienced any right shoulder or neck injuries in the years since service. The Veteran's DD 214s reflect that one of his military occupational specialties was an aircraft mechanic. He is competent to report right shoulder and neck injuries in service, symptoms of right shoulder and neck disabilities, and a continuity of symptomatology. See Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336. Moreover, there is nothing to explicitly contradict his reports and they are generally consistent with the evidence of record and the circumstances of his service. Therefore, his reports of in-service right shoulder and neck injuries and of a continuity of right shoulder and neck symptomatology in the years since service are credible and conceded. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered on the basis of the places, types, and circumstances of his service, as shown by the evidence). There are conflicting medical opinions as to the etiology of the Veteran's current right shoulder and neck disabilities. The Board, therefore, must weigh the credibility and probative value of this evidence, and in so doing, may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 29-40 (1994). A physician who conducted a November 2004 VA examination concluded that in the absence of the Veteran's service treatment records, an opinion as to whether his right shoulder and neck problems were related to service could not be provided without resorting to mere speculation. The examiner explained that if the Veteran had degenerative joint disease like he had in all his other joints and spine, then the disease would be a normal process of aging. The Veteran was 74 years old at the time of the examination and it was expected that by that time he would have degenerative arthritis. However, a complete and honest opinion as to whether his right shoulder and neck problems were related to service could not be given without resorting to speculation. A May 2010 VA examination report includes an opinion that it was not likely ("less likely than not") that the Veteran's current right shoulder and neck disabilities had their onset in service or were causally related to any event in service, including the reported injury while working on an airplane. This opinion was based on the fact that the Veteran's medical records were silent for right shoulder and neck problems from the time of his discharge from service in 1963 until the recent past. For example, there was no evidence of any shoulder complaints until 2002, at which time he complained of right shoulder discomfort. Therefore, chronicity of the conditions to link the injury in service to the current right shoulder and neck complaints was not established. The examiner who conducted the October 2012 VA examinations opined that it was "less likely as not" that the Veteran's current right shoulder and neck disabilities were causally related to any incident in service, to include the reported injury while working on an airplane. Rather, the disabilities were more than likely due to the normal aging process. The examiner reasoned that because the Veteran's service treatment records were not in the claims file, his reported shoulder and neck injury in service could not be verified. There was no documentation of any right shoulder or chronic pain problems until the previous few years. Specifically, there was no evidence of any right shoulder problems until 2002, which was 45 years after the initial injury. Thus, it was highly unlikely that any true service connection existed because chronicity had not been established for an alleged injury which occurred 55 years in the past. Rather, the Veteran simply had bilateral shoulder arthritis and an arthritic neck with right radicular findings. These problems were part of the normal aging process. In March 2013, the Board sought to obtain an expert medical opinion through the Veterans Health Administration (VHA opinion) in accordance with the provisions of 38 C.F.R. § 20.901(a) (2012). In April 2013, a VA physician reviewed the Veteran's claims file and opined that it was likely ("at least as likely as not"/"greater than 50 % probability") that his current right shoulder and neck disabilities had their onset in service and were related to his reported injury while working on an airplane. The physician explained that the Veteran experienced objective limitation of motion of the right shoulder as well as limited motion of the neck on the right side. Also, there was confirmatory evidence of osteoarthritic changes in the right shoulder and cervical spine, and these findings were entirely in keeping with the Veteran's history of injury as given and were consistent with his complaints over many years. The November 2004 opinion is adequate to the extent that it is accompanied by a specific rationale addressing why a definitive conclusion as to whether the Veteran's current right shoulder and neck disabilities were related to service could not be made. See Jones v. Shinseki, 23 Vet. App. 382 (2010). Nevertheless, the examiner stated that an opinion could not be provided without resort to speculation and this statement weighs neither for nor against the claim. Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). The May 2010 and October 2012 opinions are of limited probative value because they are entirely based upon a lack of objective clinical evidence of right shoulder and neck problems in service or for many years after service. Moreover, these opinions do not reflect consideration of the Veteran's competent and credible reports of right shoulder and neck injuries in service and of a continuity of symptomatology in the years since service. In this regard, a medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). Additionally, the May 2010 and October 2012 opinions are based on an inaccurate history concerning the Veteran's right shoulder. Although the examiners reasoned that there was no evidence of any right shoulder problems until 2002, the Veteran reported in a November 1990 statement (VA Form 21-4138) that he experienced problems due to a pulled right shoulder muscle. Thus, as the opinions are based on an inaccurate history they are of little probative value. Boggs v. West, 11 Vet. App. 334, 345 (1998); Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994) (finding that presumption of credibility of evidence did not arise as to medical opinion that a veteran's disability was incurred in service because it was based on an inaccurate history, one which failed to acknowledge an injury well-documented in the record, and hence holding such evidence not "material"); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (finding that presumption of credibility did not arise because physician's opinion was based upon "an inaccurate factual premise" and thus had "no probative value"). The April 2013 opinion, however, was based upon a review of the Veteran's medical records and reported history and is accompanied by a specific rationale that is not inconsistent with the evidence of record. Thus, this opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). In sum, the weight of the evidence is in favor of a conclusion that the Veteran's current right shoulder disability and neck disability with associated headaches are related to service. Hence, the criteria for service connection have been met and the appeal is granted. 38 U.S.C.A. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303. 2. 1151 Claim The Veteran filed his claim for compensation under the provisions of 38 U.S.C.A § 1151 in July 2000. The version of 38 U.S.C.A. § 1151 applicable to claims filed on or after October 1, 1997 provides that compensation shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151. A disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of a veteran's willful misconduct and (1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a VA (Department) employee or in a Department facility as defined in 38 U.S.C.A. § 1701(3)(A), and (2) the proximate cause of the disability or death was (a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (b) an event not reasonably foreseeable. Id. The implementing regulation applicable to 1151 claims received on or after October 1, 1997, is 38 C.F.R. § 3.361, which provides that, in order to determine whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program upon which the claim is based to the veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in a veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability or death as explained in 38 C.F.R. § 3.361(c) and that (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). In this case, the Veteran claims that he is entitled to compensation under the provisions of 38 U.S.C.A. § 1151 because he has a current gastrointestinal disability which is due to medications he was given (e.g. Propulsid/cisapride, Coumadin/warfarin) while being treated by VA in 1997, including at VAMC Oklahoma City from October to November 1997. Private treatment records, including a December 2002 examination report from Ricky Y. Ho, M.D., a December 2002 letter from Lesley Serrano, M.D., and a May 2003 pathology report from United Regional Health Care System, include diagnoses of gastroesophageal reflux disease (GERD), a bleeding ulcer, a colon polyp, and probable diverticular disease and irritable bowel disease. Thus, current gastrointestinal disabilities have been demonstrated. Treatment records from Bethania Regional Health Center dated in February and September 1997 reveal that the Veteran reported epigastric pain. He was diagnosed as having upper gastrointestinal bleeding, heme-positive stool, a duodenal ulcer, diverticulosis of the colon, and multiple colon polyps. A VA discharge summary dated in November 1997 reflects that the Veteran was admitted to VAMC Oklahoma City on October 31, 1997, secondary to newly diagnosed atrial fibrillation of unknown duration. He presented for an elective automatic implantable cardioverter-defibrillator replacement. He was started on Coumadin, among other medications, and was discharged in stable condition on November 3, 1997. He was prescribed Coumadin and cisapride at the time of discharge. Subsequent to his discharge from VAMC Oklahoma City, the Veteran experienced hypotension, dark and tarry stools, dizziness, weakness, tiredness, and thoracic pain. He sought private medical treatment and received multiple blood transfusions. Gastrointestinal problems have reportedly continued ever since that time. Diagnoses of a gastrointestinal bleed, a malignant polyp, and a bleeding prepyloric ulcer were provided. The November 2004 VA examination report includes an opinion that cisapride did not lead to the Veteran's duodenal ulcer. Although the use of Coumadin did lead to gastrointestinal bleeding, the Veteran already had a duodenal ulcer prior to being placed on the medication. Coumadin does cause bleeding, and such bleeding is sometimes an expected side effect of the medication. Thus, the examiner who conducted the November 2004 VA examination concluded that the Veteran had experienced gastrointestinal bleeding (not a duodenal ulcer) as a result of the medications prescribed by VA, but that it was not due to carelessness, negligence, or lack of proper skills. Coumadin can lead to excessive bleeding and it is a potential side effect of the medication. The physician who conducted the May 2010 VA examination opined that it was "as likely as not" that Coumadin led to the Veteran's gastrointestinal hemorrhage, but that there was no evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing treatment. She reasoned that the Veteran's medical records documented a gastrointestinal hemorrhage in 1997, at which time he received treatment at the United Regional Hospital in Wichita Falls, Texas. At that time, he was being treated with Coumadin for new onset atrial fibrillation. He was also being treated with Propulsid which had been prescribed by VA. He evidently had a history of gastrointestinal hemorrhage prior to 1997, however the records did not clearly document that he had disclosed this to the healthcare staff prior to being prescribed Coumadin in 1997. The examiner further explained that Coumadin does reduce the blood's ability to coagulate and increases the risk for hemorrhage; however, this is a well-documented potential complication of Coumadin treatment which is clearly explained to patients prior to the initiation of Coumadin therapy. The medical records did not indicate that the Veteran had disclosed to the hospital staff before the initiation of Coumadin therapy the fact that he had experienced a prior gastrointestinal bleed. The May 2010 VA examination report also includes an opinion that it was "less likely than not" that the Veteran's use of Propulsid lead to his duodenal ulcer. There was no further explanation or reasoning provided for this opinion. The examiner who conducted an October 2012 VA examination explained that the Veteran exhibited no gastrointestinal disability at all as a result of medication prescribed by VA in 1997. He had not exhibited any gastrointestinal disability since 2001 as a result of medication prescribed by VA in 1997. The upper gastrointestinal bleed in 1997 was probably due to the Coumadin prescribed for atrial fibrillation. The Veteran was fine when he was discharged from VA on November 3, 1997 and he did not begin to bleed until 10 days later. When he was admitted to a private hospital on November 13, 1997 he had an upper gastrointestinal bleed with active peptic ulcer and he required cauterization and transfusion. However, he had not experienced any problems since that time. The October 2012 examiner additionally explained that gastrointestinal bleeding is a known complication of anticoagulation, but that the medication was necessary to protect the Veteran from the life threatening effects of atrial fibrillation. The Veteran was fully aware of the potential risks at the time of the treatment. Also, he had a history of heavy alcohol use and this would have also caused some problems in the gastrointestinal tract. Thus, the examiner opined that VA was not at fault in this case. Also, he noted that he had reviewed the May 2010 VA examination report and that he fully concurred with the opinions contained therein. In May 2013, a VA gastroenterologist reviewed the Veteran's claims file and opined that "it [was] not at all likely" that any of the Veteran's current gastrointestinal disabilities diagnosed since July 2000 (including GERD, a bleeding ulcer, a colon polyp, and probable diverticular disease and irritable bowel disease) were caused or chronically worsened by VA treatment (including medications prescribed, such as Propulsid/cisapride and Coumadin/warfarin) in 1997, including treatment at VAMC Oklahoma City from October to November 1997. He reasoned that Propulsid/cisapride is sometimes an effective adjunctive therapy to decrease gastro-esophageal reflux, but that there was no evidence that it was causative of GERD, bleeding ulcers, colon polyps, diverticular disease, or irritable bowel disease. Coumadin/warfarin, by decreasing the ability of a patient's blood to clot, can increase the possibility of bleeding from a pre-existing ulcer (as occurred in the case of the Veteran). There, however, was no evidence that the medication was causative of GERD, ulcers, esophageal reflux, diverticular disease, or irritable bowel disease. Moreover, there was no evidence that Coumadin/warfarin chronically worsens any of these conditions. In light of the fact that it was not at all likely that any of the Veteran's current gastrointestinal disabilities were caused or chronically worsened by VA treatment, the gastroenterologist further opined that it was also not at all likely that the cause of the current gastrointestinal disabilities was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. Also, the question of whether such presumed, but unlikely, cause and effect relationship between the current gastrointestinal disabilities and VA treatment was foreseeable did not apply. The November 2004, May 2010, and October 2012 opinions are all insufficient because they did not identify the Veteran as having any current gastrointestinal disability and they only pertained to the gastrointestinal problems that he had experienced in 1997. In this regard, the requirement for a current disability is satisfied if there is evidence of the disability at any time since the Veteran's claim was received in July 2000, even if the disability is currently in remission. McClain v. Nicholson, 21 Vet. App. 319 (2008). As explained above, the Veteran has been diagnosed as having several current gastrointestinal disabilities. Thus, the November 2004, May 2010, and October 2012 opinions are not probative as to the etiology of his current gastrointestinal disabilities. The May 2013 opinion, however, was based upon a review of the Veteran's medical records and reported history and is accompanied by a specific rationale that takes into consideration the Veteran's currently diagnosed gastrointestinal disabilities and is not inconsistent with the evidence of record. Thus, this opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App at 304. The Veteran has expressed his belief that his current gastrointestinal disabilities are related to VA treatment in 1997 (including the use of various medications). As a lay person, however, he can only comment as to symptoms and immediately-observable relationships. He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his current gastrointestinal disabilities are related to any specific VA treatment, as opposed to some other cause. Rather, it would require medical expertise to evaluate the disabilities, consider all the potential causes, and determine that one was a more likely cause than another. Hence, the Veteran's opinion on this question is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2) (2012). Although the Veteran has received treatment from medical professionals for his current gastrointestinal disabilities, none have attributed these disabilities to any VA treatment (including any medication use). Also, the only probative medical opinion of record indicates that no relationship exists between the Veteran's current gastrointestinal disabilities and any VA treatment in 1997. There is no other evidence of a relationship between the Veteran's current gastrointestinal disabilities and any VA treatment, and neither he nor his representative have alluded to the existence of any such evidence. The Board does note that in statements dated in May 2009 and October 2010, the Veteran's representative provided information from medical literature pertaining to the side effects of various medications (including Coumadin) and the problems that may occur due to various drug interactions. Generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case, does not provide competent evidence to satisfy the nexus element for an award of compensation under the provisions of 38 U.S.C.A. § 1151. See Sacks v. West, 11 Vet. App. 314 (1998). In this case, no medical professional has specifically related any such information contained in the referenced medical literature to the Veteran. Thus, the preponderance of the evidence is against a finding that there is a link between any of the Veteran's current gastrointestinal disabilities and VA treatment (including his treatment at VAMC Oklahoma City from October to November 1997). For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt doctrine is therefore not for application in this case and the claim for compensation under the provisions of 38 U.S.C.A. § 1151 for a gastrointestinal disability must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. ORDER Entitlement to service connection for a right shoulder disability is granted. Entitlement to service connection for a neck disability with associated headaches is granted. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for a gastrointestinal disability is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs