Citation Nr: 1329008 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 07-31 012A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance of another person or on account of being housebound. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran has verified active duty service in the United States Army from June 1968 to June 1971 and from January 1991 to May 1991, with additional unverified service in the Army Reserve. Official service personnel records confirm the Veteran served in the Southwest Asia theater of operations from January 1991 to May 1991 and is thereby a Persian Gulf Veteran. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in December 1992 and October 2006 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied entitlement to the benefits currently sought on appeal. In January 2009, the Board denied the Veteran's claim for SMC based on the need for aid and attendance of another person or on account of being housebound. He appealed to the United States Court of Appeals for Veterans Claims (Court) which, by Order dated September 25, 2009, granted a Joint Motion for Remand (Joint Motion). Pursuant to the Joint Motion, the parties agreed that there were a number of unadjudicated pending claims, with jurisdiction resting both at the Board and at the RO levels, resolution of which may ultimately affect the special monthly compensation determination. Both of the issues listed on the cover page of this document have been determined by the Joint Motion to be perfected for the Board's consideration. The Board remanded the above claims for further development in July 2010 and again in June 2013. The claims again are before the Board. The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. As discussed in the July 2010 and June 2013 Board remands, the parties agreed in the September 2009 Joint Motion that several claims were pending before the agency of original jurisdiction (AOJ), but remained unadjudicated. Specifically, these issues were entitlement to service connection for respiratory distress, loss of motor control, back pain, joint pain, cardiac disorder, cerebral atrophy, seizure disorder, irritable bowel syndrome, chronic fatigue syndrome, and memory loss (all to include as a result of undiagnosed illness). The July 2010 Board remand referred these issues to the AOJ. As will be discussed in greater detail below, however, there is no indication that the AOJ has adjudicated these claims. While, an April 2012 memorandum from the Appeals Management Center (AMC) to the RO directed that the RO adjudicate the claims, again, there is no evidence in the paper claims file or the Veteran's Virtual VA electronic claims file that any steps in this regard have been undertaken. As at the time of the Board's July 2010 and June 2013 remands, the Board does not have jurisdiction over these issues as of yet, and they are REFERRED to the AOJ for appropriate action. FINDINGS OF FACT 1. On May 30, 2012, prior to the promulgation of a final decision in the appeal, the Board received written notification from the Veteran that a withdrawal of the appeal of entitlement to SMC based on the need for aid and attendance of another person or on account of being housebound was requested. 2. Clear and unmistakable evidence demonstrates that the Veteran's hypertension preexisted his final period of active duty service, and clear and unmistakable evidence demonstrates that the hypertension was not aggravated by service or service-connected disability, as any increase in disability was due to the natural progression of the disease. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the substantive appeal by the Veteran for the issue of entitlement to SMC based on the need for aid and attendance of another person or on account of being housebound have been met. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.202, 20.204(b), (c) (2012). 2. The criteria for establishing entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.310 (2006); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's service connection claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran 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 Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in July 2010 and July 2013 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letters informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The July 2013 letter also explained how to establish entitlement to service connection on a secondary basis. The letters also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veteran Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of entitlement to service connection. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file, to include those directed by previous Board remand. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. 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. 38 C.F.R. § 3.159(c)(4)(i) (2012). In that regard, the Veteran was provided a general VA medical examination in June 1992, where he was diagnosed with hypertension. In addition, as directed by the July 2010 Board remand the Veteran was afforded VA examinations for his hypertension claim in August 2010. Finally, a July 2013 VA examination was conducted to consider the merits of the Veteran's contention that his hypertension was caused or aggravated by his service-connected psychiatric problems. The Board finds the August 2010 and July 2013 VA examination reports to be thorough and complete. The opinions expressed were based on the Veteran's reported history and review of the claims file. The opinions were supported by a complete rationale. Based on the opinions of record and the fact there is no rule as to how current an examination must be, the Board concludes the opinions in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Based on the July 2010 and July 2013 VA notice letters, the association of VA treatment records, the August 2010 and July 2013 VA examinations, and subsequent readjudication of the claims, the Board finds that there has been substantial compliance with its July 2010 and June 2013 remand directives with respect to the above hypertension claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Withdrawal of Claim for SMC Benefits Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202 (2012). Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204 (2012). As discussed above, the June 2010 Board remand included the issue of entitlement to SMC based on the need for aid and attendance of another person or on account of being housebound. Following the readjudication of the claim in a May 2012 supplemental statement of the case (SSOC), the Veteran indicated in a written statement received on May 30, 2012, that "I want to WITHDRAW the issue regarding Special Monthly Compensation based on the need for Aid and Attendance because I do NOT meet the criteria." Hence, there remains no allegation of errors of fact or law for appellate consideration regarding that claim. Accordingly, the Board finds that the issue of entitlement to SMC based on the need for aid and attendance of another person or on account of being housebound has been properly withdrawn by the Veteran and dismisses the claim. In reaching that decision, the Board acknowledges that in June 2013 the Board remanded the SMC claim, rather than dismissing it based on the Veteran's requested withdrawal of the claim. That said, subsequent statements from the Veteran and his representative have not specifically indicated that they wished the SMC claim to continue despite the request to withdraw and the information obtained as a result of the June 2013 remand does not support the grant of SMC benefits. As such, the Board does not find that the Veteran would be prejudiced by dismissing the SMC claim as requested by the Veteran in May 2012 as there is no evidence that the Veteran relied on the Board's June 2013 remand and/or subsequent August 2013 SSOC to his detriment. Cf. Percy v. Shinseki, 23 Vet. App. 37 (2009) (holding that VA waived any objections as to the content of the appeal by treating the issue as on appeal for five years). Service Connection for Hypertension Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). 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) (2012). 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). Service connection for certain chronic diseases, including cardio-vascular renal disease (including hypertension), will be presumed if they are manifest to a compensable degree within one year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2010). However, the Veteran was not diagnosed with hypertension during or within one year of his first period of active service and, instead, was diagnosed with hypertension prior to his second period of active service. As such, service connection for hypertension may not be granted on a presumptive basis. In this case, the Veteran claims that he permanently aggravated a preexisting hypertension condition as the result of his second period of military service, from January 1991 to May 1991. Specifically, the Veteran asserts that his blood pressure rose while serving in Southwest Asia, requiring bed rest, and that his hypertension underwent a permanent increase in severity as a result of his second period of active service. In the alternative, the Veteran also has contended that his hypertension was permanently aggravated by his service-connected psychiatric disorder. 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 the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The Veteran 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. VAOPGPREC 3-2003 (July 16, 2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such 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(a) (2012). For Veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Initially, the Board notes that a medical examination is not of record at the time of the Veteran's entrance into his second period of active service in January 1991. As such, the Veteran will be presumed to have entered service in sound condition with respect to his hypertension. 38 U.S.C.A. §§ 1111 (West 2002); see also Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). As noted, however, the presumption can be rebutted by clear and unmistakable evidence. In this case, the evidence of record clearly establishes the Veteran's hypertension preexisted his second period of active service beginning in January 1991. The Veteran's service treatment records show no evidence of a diagnosis or evidence of a hypertension disability during his initial period of military service or within one year thereafter. Indeed, the Veteran does not contend that his current hypertension began during such a period. Instead, the evidence of record demonstrates that the Veteran was diagnosed with hypertension in approximately 1975, as reported during his June 1992 general VA medical examination. A June 1990 private treatment record noted prescription of Visken for the Veteran's blood pressure since 1984. A November 1992 private treatment record indicated a diagnosis of hypertension in approximately 1980. Multiple other documents and the Veteran's lay contentions establish a diagnosis of hypertension prior to the Veteran's entrance into active service in January 1991. While there is some disparity in the actual date of diagnosis, the Veteran clearly was diagnosed with hypertension more than one year after his first separation from active service and prior to his second period of active service. In that regard, the Board notes that the Veteran is competent to report a contemporaneous diagnosis made by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In light of the foregoing, the Board finds that there is clear and unmistakable evidence of record that the Veteran's hypertension preexisted service from January 1991 to May 1991. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). In reaching that conclusion, the Board acknowledges that the presumption of soundness on entrance cannot be overcome simply based on the representations of the Veteran during the entrance examination or thereafter. See Miller v. West, 11 Vet. App. 345, 348 (1998) (holding that a veteran's self-report that he had previously suffered from "depression or excessive worry" prior to service was insufficient to rebut the presumption of soundness as was found in 38 U.S.C.A § 1111); see also Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In this case, however, there is both clinical and lay evidence of the preexisting disorder, both prior and subsequent to his entrance into service in January 1991. As set forth in VAOPGCPREC 3-2003, the Board must also determine if there is clear and unmistakable evidence that the disorder was not aggravated during service. In this case, the Board finds clear and unmistakable evidence establishing that the Veteran's hypertension was not permanently aggravated by service beyond the natural progression of the disease. In that regard, the Veteran submitted a January 1993 statement from a fellow service member that noted the Veteran had increased blood pressure readings during service that were attributed to a large increase in water consumption due to the sodium contained in some brands of bottled water. The statement indicated that for several weeks the Veteran drank only a brand of bottled water with a low sodium content and that he reported feeling better thereafter, although he continued to take medication and monitor his blood pressure. An April 1991 Report of Medical History indicated that the Veteran was in good health and taking 5 m.g. of Visken daily to control his blood pressure. The Veteran does not appear to have undergone a complete separation examination in May 1991, other than audiological testing. A July 1991 private treatment record shortly after separation from service noted that the Veteran, was in Desert Storm, and when he was over there, he had some water that had a lot of sodium in it. His pressure went up at that point, but other than that it has been good. The diastolic has always been below 90 other than when he was drinking that water. He is continuing on his Visken 1 q.d. He has checked his BP in the a.m. and in the p.m. and it has been okay. At that time, the treatment provider prescribed "Visken 5 mg. 1 p.o. q.d. #31" and this prescription is precisely the same as the prescription given the Veteran in June 1990, which is the last treatment for hypertension of record prior to his second period of active service. As shown by the foregoing, the evidence shows a temporary increase in blood pressure during military service due to the consumption of large amounts of bottled water that contained sodium and that following the cessation of such activity the Veteran's blood pressure returned to baseline. Moreover, after reporting the in-service experience to his private treatment provider shortly after separation from service, that treatment provider made no change to his pre-service level of blood pressure medication or other change in treatment for the Veteran's hypertension. Indeed, the private treatment provider specifically noted that other than the single in-service incident involving increased blood pressure due to drinking bottled water with a higher sodium content that the Veteran's blood pressure had been "good." Thus, in the immediate aftermath of the Veteran's second period of service, there is no evidence of a permanent aggravation of his preexisting hypertension disability. In May 1992, the Veteran was seen following an emergency room visit three weeks previously when his blood pressure had been 187/110. At that time they increased his Visken blood pressure medication, but since that time he had noticed increased dizziness and lethargy. As such, the treatment provider discontinued the Visken and prescribed Cardizem 180 mg. daily. Initially, the Veteran noted improvement; however, over the subsequent months his prescription was increased to 240 mg. and then 300 mg. daily due to poor blood pressure control. Altace subsequently was added to the Cardizem. In approximately December 1993, however, the Veteran's blood pressure medication was wholly discontinued. Instead, the use of antidepressants was used to treat the Veteran's episodic high blood pressure. Such treatment has continued to the present. As described by the Veteran during his April 1996 RO hearing, his high blood pressure is associated with periods of tension, such as when visiting a medical facility or a physician. The Veteran was afforded a general VA examination in August 2010. The examiner extensively discussed the Veteran's treatment history. On examination, the Veteran's blood pressure was 134/94, 140/90, and 149/88 on various arms and in standing and sitting positions. The examiner diagnosed essential hypertension. The examiner concluded that the hypertension was not caused by military service because it was diagnosed between periods of active service. The preponderance of the evidence also did not support the aggravation beyond its natural progression by the second period of service. The Veteran was afforded another VA examination in July 2013. The examiner noted review of the claims file. The examiner noted a diagnosis of hypertension from 1975. The Veteran reported that his blood pressure was well controlled on medication for 10 years, until his second period of military service. While in Southwest Asia the Veteran began to feel poorly, but stated that he was not treated by military personnel for the problem but was monitored and continued to take the medication prescribed by his private physician. In 1993, the Veteran was diagnosed with PTSD at the Vet Center. For the past few years, the Veteran reported that his blood pressure had been well controlled and the examiner noted that VA treatment records supported that assessment. The Veteran denied hospitalization or complications from hypertension and currently was asymptomatic for hypertension. The examiner discussed the Veteran's treatment history. The examiner diagnosed essential hypertension, which was well controlled by oral medication and was not permanently aggravated by the Veteran's service-connected PTSD. The rationale was that the preponderance of the medical evidence and expertise did not support the proximate causation or aggravation of hypertension by PTSD. In other words, there was no medical or clinical correlation between the two separate medical conditions and that one did not cause the other. Thus, the medical opinions of record, in addition to the contemporaneous medical evidence of record, do not support a finding that the Veteran's preexisting hypertension was permanently aggravated beyond its natural progression by his second period of service. The August 2010 VA examiner specifically considered the Veteran's contentions, but concluded that the preponderance of the evidence was against concluding that the preexisting hypertension was aggravated by the Veteran's second period of service. While the August 2010 examiner did not use the term "clear and unmistakable" it is clear in context that the examiner found no basis to conclude that the Veteran's hypertension was permanently aggravated by his second period of military service. The examination report documented multiple treatment records that indicated periods of reduced blood pressure in 1994 and generally from 2005 through 2009, as opposed to a period of increased blood pressure in 2004. The August 2010 VA examiner's conclusions are further supported by the above noted treatment records that shortly after separation from service documented no blood pressure problems other than the single in-service incident due to the salt content of consumed bottled water. To the extent that the Veteran subsequently incurred increased blood pressure readings at periods in April and/or May 1992 and intermittent periods thereafter, the Veteran has conceded and the July 2013 VA examiner agreed that the Veteran's hypertension has been well controlled over the past years despite these intermittent spikes in blood pressure. Indeed, the only probative evidence that the Veteran's hypertension was permanently aggravated by service is his own lay assertions. However, the Veteran has conceded on multiple occasions that other than the single incident involving excessive salt in consumed bottled water that the Veteran had no problems with his blood pressure during service. To the extent that he claims otherwise, such assertions are inconsistent with the January 1993 buddy statement and July 1991 private treatment record. The Board affords far greater weight to the contemporaneous reports of symptoms made for the purpose of obtaining medical treatment than statements made years after the fact in pursuit of VA compensation benefits. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence."); see also Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that in weighing an applicant's credibility, the Board may consider any evidence of interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, and desire for monetary gain). With respect to the Veteran's assertions that any increased blood pressure problems following his second separation from military service was the result of that military service, the Board does not find the Veteran competent to attribute blood pressure problems that began months after his second separation from service and occurred intermittently over the years thereafter to his military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As such, the Board affords those assertions no probative weight. Based on the evidence of record, the Board concludes that there is clear and unmistakable evidence that the Veteran's preexisting hypertension was not permanently aggravated by his service period of military service from January 1991 to May 1991. In addition, the Board has considered the Veteran's claim that his hypertension disability was aggravated by his service-connected PTSD disability. (As the Veteran's PTSD was the result of events in Southwest Asia that occurred many years after his diagnosis with hypertension, the Board finds no evidence that the service-connected PTSD caused the Veteran's hypertension.) Any disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. See 38 C.F.R. § 3.310 (2006). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The Board observes that the provisions of 38 C.F.R. § 3.310 were amended, effective as of October 20, 2006, during the pendency of the instant appeal. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by service-connected one is judged. Although the VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the Veteran to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection based on aggravation may be made. This had not been the VA's practice and thus suggests that the recent change amounts to a substantive change in the regulation. For this reason and as the Veteran's claim was pending before the regulatory change was made, the Board will consider his claim under the prior version of 38 C.F.R. § 3.310 as it is more favorable to the Veteran. In addition and as discussed above, the July 2013 VA examiner considered the Veteran's assertions that his service-connected psychiatric disorder aggravated his hypertension disability. After considering the Veteran's contentions and the other evidence of record, the examiner concluded that his hypertension was not permanently aggravated beyond its natural progression by the Veteran's PTSD. The examiner provided a sufficient rationale for the conclusion, namely that the preponderance of the medical evidence and expertise did not support an association between PTSD and hypertension. The Board finds this opinion to be the most probative evidence of record. The Board has considered the statements of the Veteran that treatment providers had told him that his hypertension was caused or aggravated by his PTSD. While the Board recognizes that the Veteran is competent to report a contemporaneous medical diagnosis, Jandreau, 492 F.3d at 1377, the Board finds that his competence to relate a complex rationale as to the etiology of a current disability is less certain. As the Court has previously noted, "the connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence." Robinette v. Brown, 8 Vet. App. 69, 77 (1995). As such, the Board finds the Veteran's representations as to opinions related to him by private treatment providers to be of extremely limited probative value. As to any other representations of the Veteran that his hypertension was caused or aggravated by his service-connected psychiatric disorder, the Board finds such conclusions beyond his competency as a layperson. See Jandreau, 492 F.3d at 1377. Finally, the Board recognizes that the Veteran served in the Southwest Asia theater of operations from January 24, 1991 to April 1, 1991, potentially raising the applicability of 38 U.S.C.A. § 1117 (West 2002) and 38 C.F.R. § 3.317 (2012). In that regard, the Board notes that cardiovascular signs and symptoms are observed to be an example of the signs or symptoms of undiagnosed illness or medically unexplained chronic multisymptom illness as defined in the foregoing. In this case, however, as discussed above the Veteran's blood pressure problems have been definitively diagnosed as hypertension and, moreover, were diagnosed years prior to his service in the Southwest Asia theater of operations. As such, the above provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 are inapplicable. Therefore, in summary, the Board finds that the credible and probative evidence of record clearly and unmistakably shows that the Veteran's hypertension preexisted service and was not aggravated therein beyond the natural progression of the disease. In addition, the preponderance of the evidence is against finding that the Veteran's hypertension was caused or aggravated by his service-connected PTSD. For this reason, the Board finds that service connection for hypertension is denied. ORDER The appeal regarding the claim of entitlement to SMC based on the need for aid and attendance of another person or on account of being housebound is dismissed. Entitlement to service connection for hypertension is denied. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs