Citation Nr: 1329003 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 09-09 700 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for coronary artery disease with angina, status post coronary artery bypass graft (previously denied as a heart condition and rheumatic heart disease and hereinafter referred to as a 'heart disorder'). 2. Entitlement to service connection for peptic ulcer disease. 3. Entitlement to service connection for arthritis of the right foot. 4. Entitlement to service connection for arthritis of the left foot. 5. Entitlement to service connection for arthritis of the right hand. 6. Entitlement to service connection for arthritis of the left hand. 7. Entitlement to service connection for arthritis of the right ankle. 8. Entitlement to service connection for arthritis of the right elbow. 9. Entitlement to service connection for residuals of a perforated left eardrum. 10. Entitlement to service connection for bilateral hearing loss. 11. Entitlement to service connection for tinnitus. 12. Entitlement to service connection for dizzy spells. WITNESSES AT HEARING ON APPEAL The Veteran, J.D.T., A.T., D.B., and R.S. ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1953 to October 1955 and periods of reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. A Travel Board hearing was held in December 2012 before the undersigned Veterans Law Judge (VLJ). The case was last before the Board in April 2013, and remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his appeal, to include obtaining treatment records and records from the Social Security Administration (SSA) and to afford the Veteran a new VA examination. The Veteran's most recent VA treatment records were obtained and associated with the claims file. Records from the SSA were also associated with the claims file. The Veteran was afforded a VA examination in May 2013 for his arthritis claims. Therefore, the Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for arthritis of the left hand is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A June 1973 rating decision denied service connection for a heart disorder as the record did not establish that this disability was incurred in service. 2. Evidence received since the June 1973 rating decision denying service connection for a heart disorder is not cumulative of the evidence of record at the time of the June 1973 denial, relates to an unestablished fact necessary to substantiate the claim of service connection and raises a reasonable possibility of substantiating the Veteran's claim of service connection. 3. The preponderance of the evidence is against a finding that a heart disorder is related to service. 4. The preponderance of the evidence is against a finding that peptic ulcer disease is related to service. 5. The preponderance of the evidence is against a finding that arthritis of the right foot is related to service. 6. The preponderance of the evidence is against a finding that arthritis of the left foot is related to service. 7. The preponderance of the evidence is against a finding that arthritis of the right hand is related to service. 8. The preponderance of the evidence is against a finding that arthritis of the right ankle is related to service. 9. The preponderance of the evidence is against a finding that arthritis of the right elbow is related to service. 10. The preponderance of the evidence is against a finding that residuals of a perforated left eardrum are related to service. 11. The preponderance of the evidence is against a finding that a bilateral hearing loss disorder is related to service. 12. The preponderance of the evidence is against a finding that tinnitus is related to service. 13. The preponderance of the evidence is against a finding that dizzy spells are related to service. CONCLUSIONS OF LAW 1. The June 1973 rating decision denying service connection for a heart disorder is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 2. Evidence received since the June 1973 rating decision is new and material and the Veteran's claim of entitlement to service connection for a heart disorder is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. A heart disorder was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 4. Peptic ulcer disease was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 5. Arthritis of the right foot was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 6. Arthritis of the left foot was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 7. Arthritis of the right hand was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 8. Arthritis of the right ankle was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 9. Arthritis of the right elbow was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 10. Residuals of a perforated left eardrum were not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 11. A bilateral hearing loss disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 12. Tinnitus was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 13. Dizzy spells were not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The notice requirements were met in this case by a letter sent to the Veteran in October 2007. This letter advised the Veteran of the information necessary to substantiate his claims and of his and VA's respective obligations for obtaining specified types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). This letter also advised the Veteran of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In addition, the case of Kent v. Nicholson, 20 Vet. App. 1 (2006), requires that, prior to the adjudication of petitions to reopen service connection claims, the appellant be given notice of the elements of service connection, the elements of new and material evidence, and the reasons for the prior denial. This notice was provided in the October 2007 letter. During the December 2012 Board hearing the Judge explained the issues on appeal and asked questions designed to indicate the submission of evidence that the Veteran may have overlooked. These actions provided an opportunity for the Veteran to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The Veteran could also be expected to understand these elements based on a reading of the VCAA letter discussed above. The Veteran has not identified any prejudice in the conduct of the Board's December 2012 hearing or contended that he does not fully understand the issues or the evidence that is required to substantiate his claims. The Board finds that any error in notice provided during the Veteran's hearing constitutes harmless error. The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. The Veteran's service treatment records and VA treatment records are in the file. The Veteran has also submitted private treatment records which have been associated with the claims file. In December 2007, the RO issued a Formal Finding of Unavailability of treatment records from the Salisbury VA Medical Center for the 1976 calendar year. The Veteran has not indicated that there are any additional outstanding records to be obtained. The duty to assist with obtaining medical records has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Veteran was afforded a VA medical examination in February 2008 for his tinnitus and hearing loss claims and in May 2013 for his arthritis claims. The opinions were rendered by a medical professional following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history. The examiners provided a detailed conclusion for the opinions that were reached. Therefore, the Board finds that the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A VA examination was not provided in conjunction with the Veteran's claims for a heart disorder, peptic ulcer disease, and dizzy spells, and, as discussed below, the evidence of record does not warrant one. See 38 C.F.R. § 3.159(c)(4). In the present case, there is no competent evidence of record to support a finding that the Veteran's claimed disorders are related to service. The Veteran has alleged that these disorders are related to service, and although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), determining the etiology and diagnosis of a heart disorder, stomach disorder, and dizzy spells falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Waters v. Shinseki, 601 F.3d 1274, 1279 (Fed. Cir. 2010) (the Veteran's conclusory lay statement is insufficient to trigger VA's duty to provide an examination with an opinion). The Veteran has not satisfied all the elements of McLendon as to these claims and VA is not required to provide him with a VA examination in conjunction with these asserted disorders. In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the Veteran in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. New and Material Evidence Previously denied claims may be reopened with the submission of new and material evidence. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. §§ 3.156, 20.1105 (2012). "[N]ew evidence" means evidence not previously submitted to agency decision-makers, and "material evidence" means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is 'low.' Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The Veteran's claim of entitlement to service connection for a heart disorder was denied in a June 1973 rating decision. The Veteran did not appeal this decision and it is final. 38 U.S.C.A. § 7105. The evidence received since the June 1973 rating decision includes VA treatment and private treatment records and the Veteran's statements and hearing testimony. Specifically, the Veteran's records from the SSA note that he has been diagnosed with heart disease, status post coronary bypass graft, and coronary artery disease. He has also had a myocardial infarction. The Veteran also testified in May 2013 that when he separated from service he had a heart disorder. The Veteran's daughter also testified that the Veteran was supposed to receive treatment for a heart disorder prior to his separation, but that he did not as there were no facilities available. This evidence is new, as it was not previously of record at the time of the June 1973 rating decision. It is also material in that it helps to support the Veteran's contentions that his claimed heart disorder is related to service. Therefore, the claim is reopened. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment. 38 C.F.R. § 3.304(b). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. In order to rebut the presumption of sound condition, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progression of the preexisting condition. 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Wagner, supra. If this burden is met, then the Veteran is not entitled to service-connected benefits. Wagner at 1096. Service connection may also be granted for a chronic disease, including arthritis and hearing loss, when it is manifested to a compensable degree within one year of separation from service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a 'competent' source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, 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, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Heart Disorder, Peptic Ulcer Disease, Perforated Left Eardrum, Hearing Loss, and Tinnitus The Veteran contends that he is entitled to service connection for the above claimed conditions as they all occurred in service. The preponderance of the evidence is against these claims, and the appeal will be denied. For purposes of a hearing loss claim, impaired hearing will be considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, 4,000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 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 (2012). The report of a February 2008 VA audiology examination indicates the Veteran currently has a bilateral hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. The Board has reviewed the Veteran's service treatment records and there is no evidence that he complained of, was diagnosed with, or was treated for any of the above claimed conditions while in service. At his entrance examination in September 1953 the Veteran himself denied ear trouble and his hearing was normal on examination, 15/15. He had a slight thickening of both eardrums and a slight pulmonic systolic murmur, apparently functional. A March 1955 x-ray showed no evidence of active pulmonary, cardiovascular, or diaphragmatic pathology. A September 1955 examination revealed no heart, stomach, or ear disorders. Again in April 1956 the Veteran denied ear trouble, stomach trouble, frequent indigestion, palpitation or pounding heart on his Report of Medial History. On examination the only defects noted were poor oral hygiene, mild internal [strabismus], and acne vulgaris. This evidence weighs against the Veteran's claim that a heart disorder, ulcer disease, hearing loss, tinnitus and perforated eardrum began in service. When the Veteran entered service in September 1953 the examiner noted a slight heart murmur. Accordingly, the Veteran is not presumed sound on entrance to service. See Wagner, supra; 38 C.F.R. § 3.304(b). In reviewing the service treatment records there is no evidence that the Veteran's heart condition worsened during service. To the contrary, there was no notation of worsening on follow up examination reports in September 1955 or April 1956. A March 1955 x-ray showed no heart disorder. The Veteran also has not alleged that his pre-existing heart condition worsened in service. Accordingly, the Board finds that the Veteran's pre-existing heart murmur was not aggravated by active service. There is also no evidence that the Veteran had hearing loss that manifested to a compensable degree within one year of separation of service. The presumption of service connection does not therefore apply. 38 U.S.C.A. §§ 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The Veteran filed a claim of service connection in April 1973, 18 years after separation from service, for heart and dental conditions. He did not report having peptic ulcer disease, hearing loss, tinnitus or ear problems on this claim. At his May 1973 examination the Veteran had a normal electrocardiogram. The Veteran also filed a claim for pension in October 1993 claiming a heart condition. The Veteran did not file his current claim until December 2006, over 50 years after separation from service. This evidence weighs against his claim that his peptic ulcer disease, perforated left eardrum residuals, hearing loss, and tinnitus began in service and continued on thereafter. A significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The law also provides that even if a chronic condition such as arthritis is not shown during service, service connection may be established under 38 C.F.R. § 3.303(d) if the evidence shows a disease first diagnosed after service was incurred in service. In a July 1957 treatment record the Veteran was admitted to the hospital with joint pain. The examiner noted the Veteran had an excessive number of sore throats while in service, but no other trouble. On examination the Veteran had a soft systolic murmur heard at the apex. He was discharged shortly thereafter with no further follow up. In a December 1962 treatment record the Veteran had an apical systolic murmur which was heard. No diastolic murmurs were heard. In a March 1966 x-ray the Veteran's heart and lungs were clear. In June 1991 the Veteran reported to the hospital with a rapid heartbeat. He was status post coronary bypass surgery, which was done in May 1991. See also May 1991 private treatment surgical records. He had possible cardiac arrhythmias with near syncope. The Veteran also reported some episodes of atypical chest pain post surgery. See May 1993 treatment record. The Veteran submitted an audiogram from his private audiologist from July 2007. The Veteran reported a long history of asymptomatic sensorineural hearing loss; he also reported acoustic trauma. He reported that he perforated his left eardrum in service. The examiner noted an old perforation in the right ear which had healed, but the left ear was unremarkable. The Veteran was afforded a VA audiological examination in February 2008. The Veteran reported noise exposure while in service working as a motor transport mechanic. He also had post service occupational noise exposure. The Veteran also reported tinnitus which occurred weekly for about 20 seconds. The examiner noted evidence of an old healed perforation to the tympanic membrane of the right ear. The Veteran also had mixed moderate to profound hearing loss bilaterally. The examiner did not link hearing loss or tinnitus to service. His rationale included that the Veteran had normal hearing in service with no hearing loss or tinnitus complaints. The tinnitus described by the Veteran was also not consistent with noise induced tinnitus and could be normal. The examiner also attributed hearing loss to post service occupational noise exposure. As noted, the perforated eardrum pertained to the right ear, not the left as the Veteran is claiming. In a December 2009 VA examination it was noted the Veteran had coronary artery disease and was status post coronary artery bypass graft x 3, but that his condition was stable and had no functional affect. In March 2012 the Veteran had a stress test which showed no significant changes and no arrhythmia. In a January 2013 VA treatment record the Veteran's gastroresophageal reflux disease was noted to be stable with medication. At the Veteran's December 2012 Board hearing he testified that he had a slow heart and that he had undergone surgery in the 1990's. The Veteran's daughter alleged that the Veteran was not checked sufficiently in service before he was discharged. The Veteran also testified that he was being treated for an ulcer currently which began when he was in service. He testified that he perforated his left eardrum while he was in training when a gun discharged on the ship where he was stationed. He testified he has had tinnitus since the gun discharge. There was also testimony regarding the Veteran's MOS in service and working as a rifleman without ear protection. The Veteran is competent to state his current symptoms, including irregular heartbeat, hearing loss, and tinnitus. However, while competent to discuss symptoms, the Veteran is not then competent to diagnose the etiology of the claimed disorders and relate them to service. Accordingly, the Board assigns the Veteran's statements no probative value. The Board has considered the Veteran's statements and testimony from the December 2012 hearing. As noted, although lay persons such as the Veteran are competent to provide opinions on some medical issues, see Kahana, supra., diagnosing and determining the etiology of conditions such as a heart disorder, ulcer disease, perforated eardrum, hearing loss and tinnitus, these fall outside the realm of common knowledge of a lay person. Additionally, the Veteran has offered only conclusory statements regarding the relationship between in service incidents and current claimed disorders. Accordingly, the preponderance of the evidence is against the claims of service connection for a heart disorder, peptic ulcer disease, residuals of a perforated left eardrum, hearing loss disability, and tinnitus and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Arthritis of the Bilateral Feet, Right Hand, Right Ankle, Right Elbow, and Dizzy Spells The Board has reviewed the Veteran's service treatment records and there is no evidence that he complained of, was diagnosed with, or was treated for arthritis or dizzy spells while in service. The Veteran was seen on multiple occasions, but these disorders were not reported. See e.g., Report of Medical Examination from September 1953, September 1955 and April 1956. This evidence weighs against the Veteran's claims that these disorders began in service. There is also no evidence that the Veteran had arthritis that manifested to a compensable degree within one year of separation of service. The presumption of service connection does not therefore apply. 38 U.S.C.A. §§ 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Private treatment records from July 1957, within two years of service discharge, show complaints of pain and swelling of the feet and ankles, continuing to the right knee joint and left hip. A December 1962 treatment record also noted joint pain in the left knee, right elbow and several other joints. Generalized joint pain was noted on re-evaluation in March 1966. In a May 1973 x-ray there was evidence of mild deformity of the styloid process of the right 5th metatarsal suggesting an old injury. X-rays were otherwise normal. A May 1973 VA examination revealed extensive complaints of joint pain. These treatment notations were made in the context of determining whether the Veteran has rheumatoid arthritis, a disorder for which service connection already has been denied pursuant to a final 1973 RO rating decision and is not on appeal. In a July 1991 treatment record the Veteran reported with dizzy spells of unclear etiology. In August 1993 the Veteran reported that he had been fired because he continued to have fainting spells. A July 2007 private treatment record noted the Veteran's dizzy spells may be related to his heart condition as the Veteran's dizziness seemed to be a problem when he went from sitting up after lying down. At his May 2013 VA examination the Veteran reported that he did not have joint problems during service, but that his joint became swollen just after separation from service in 1956. He reported that he was also hospitalized in 1957 and 1962 for the same symptoms. He reported that his joints ached and swelled in cold weather. He also reported that he had to quit his job when he initially had arthritis symptoms because he could not work assembling furniture. X-rays of the Veteran's right and left feet revealed no arthritis. Hallux valgus of the first toe was noted on the Veteran's right foot and his left foot showed posterior calcaneal spurring, vascular calcification, and vascular surgical clips of the ankle. No arthritis was present. The Veteran's right ankle showed evidence of old bimalleolar trauma with posterior calcaneal spurring, vascular calcification and vascular surgical clips. There was no evidence of arthritis. X-rays showed the Veteran had a normal right hand with no evidence of arthritis, although there was evidence of an old trauma to the 5th metacarpal. On x-ray the Veteran had no evidence of right elbow arthritis. The Veteran's daughter testified at his December 2012 Board hearing that he had been diagnosed with arthritis in 1968 or 1969 after he separated from service, although the Veteran testified that his hand pain began in service. The Veteran's daughter also testified that he lost his job in 1959, shortly after separating from service, because he had crippling hand pain due to arthritis. He further testified that his dizzy spells caused him to faint or fall. Although lay persons such as the Veteran and his family are competent to provide opinions on some medical issues, see Kahana, supra, as to the issue of diagnosing arthritis and dizzy spells and determining an etiology, this falls outside the realm of common knowledge of a lay person. The Veteran's assertions have been investigated by competent medical opinion, and found to be without merit. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (lay evidence may be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer, (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). Without a current diagnosis of a disability, the Board cannot grant service connection. To prevail on the issue of service connection, a current disability must have existed on or after the date of application for that disability. See 38 U.S.C.A. § 1110; see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (agreeing that the requirement that a claimant have a current disability before service connection may be awarded is satisfied when a claimant has a disability at the time a VA claim is filed or during the pendency of that claim.). There is no competent evidence of a diagnosis of arthritis of the bilateral feet, right hand, right ankle, or right elbow. There is also no diagnosis of disorder which causes dizzy spells. Accordingly, the Veteran's claims for service connection must be denied. ORDER New and material evidence having been received, the claim of entitlement to service connection for a heart disorder is reopened; to this extent only, the appeal is granted. Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for peptic ulcer disease is denied is denied. Entitlement to service connection for arthritis of the right foot is denied. Entitlement to service connection for arthritis of the left foot is denied. Entitlement to service connection for arthritis of the right hand is denied. Entitlement to service connection for arthritis of the right ankle is denied. Entitlement to service connection for arthritis of the right elbow is denied. Entitlement to service connection for residuals of a perforated left eardrum is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for dizzy spells is denied. REMAND The Veteran was afforded a VA examination in May 2013 for his arthritis claims. At this examination he was diagnosed with limited osteoarthritis of the left thumb. While the examiner determined the Veteran did not have rheumatoid arthritis, he did not offer an opinion as to whether the Veteran's left thumb osteoarthritis was related to service. Accordingly, a new opinion should be obtained. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Request that the May 2013 VA examiner offer an addendum opinion. The entire claims file (i.e., any medical records contained in Virtual VA, CAPRI, and AMIE), including this REMAND, must be reviewed by the examiner in conjunction with the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner must provide an opinion as to whether the Veteran's osteoarthritis of the left thumb is related to service. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why an opinion cannot be rendered. Merely saying (s)he cannot respond without resorting to speculation will not suffice. If another examination is deemed warranted, advise the Veteran of the importance of reporting to this additionally scheduled VA examination and of the possible adverse consequences, including the possible denial of his claim, of failing without good cause to so report. 2. Ensure this supplemental medical opinion is responsive or provides sufficient explanation as to why it cannot be. If it is not, take any needed corrective action. See 38 C.F.R. § 4.2. 3. Then readjudicate this claim. If the claim continues to be denied, send the Veteran a Supplemental Statement of the Case (SSOC) and give him an opportunity to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs