Citation Nr: 1330485 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 08-10 336 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for the cause of the Veteran's death. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from January 1942 to November 1945; he died in August 2006. The appellant is the Veteran's daughter. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Detroit, Michigan, that denied the appellant's claim of entitlement to service connection for the cause of the Veteran's death. In June 2009, the Veteran and her sister testified at a personal hearing over which the undersigned Acting Veterans Law Judge presided while at the RO. A transcript of that hearing has been associated with his claims file. The provisions of 38 C.F.R. § 3.103(c)(2) imposes two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing, the undersigned clarified the issue on appeal and inquired as to the etiology and continuity of the Veteran's asserted symptoms. The appellant was offered an opportunity to ask the undersigned questions regarding her claim. The Board, therefore, concludes that it has fulfilled its duty under Bryant. Subsequently, the appellant submitted additional evidence for which she has provided written waiver of RO review under 38 C.F.R. § 20.1304 (2013). In March 2010, the Board remanded the case for further evidentiary development. Following the requested development, a Supplemental Statement of the Case was issued in November 2011. In January 2013, the Board again remanded the case to the RO via the Appeals Management Center (AMC). Following the requested development, an Supplemental Statement of the Case was issued in March 2013. As discussed below, the Board finds that there was substantial compliance with its remand; thus, it may proceed with a decision at this time. See Stegall v. West, 11 Vet. App. 268 (1998). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with this claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDINGS OF FACT 1. The Veteran died in August 2006 at the age of 84. According to the death certificate, the immediate cause of death was end-stage cardiac disease. No other significant condition contributing to death was reported on the death certificate. No autopsy was performed. 2. At the time of the Veteran's death, service connection was in effect for post-traumatic stress disorder (PTSD), rated as 50 percent disabling. 3. There was no disability present in service and no evidence of asbestos exposure during service. 4. The Veteran's end-stage cardiac disease was not manifested in service or in the first post-service year, and it is not shown to be related to the Veteran's period of active service, to include any exposure to asbestos. 5. The Veteran was diagnosed with asbestosis, which would suggest asbestos exposure; however, there is no competent medical evidence that the Veteran's death was related to any lung disease or asbestos exposure. 6. The Veteran's service-connected PTSD is not shown to have caused or contributed materially in producing or accelerating the Veteran's demise. CONCLUSIONS OF LAW 1. The Veteran's death was not due to disease or injury that was incurred in or aggravated by active service, to include exposure to asbestosis. 38 U.S.C.A. §§ 1110, 1131, 1310, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.312 (2013). 2. A service-connected disability did not cause or contribute substantially or materially in producing the Veteran's death. 38 U.S.C.A. §§ 1310, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide; and to request that the claimant provide any evidence in the claimant's possession that pertains to the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a Statement of the Case or Supplemental Statement of the Case. Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Additionally, in the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, 38 U.S.C.A. § 5103(a) notice must include (1) a statement of the conditions, if any, for which a Veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). In this case, VA satisfied its duty to notify by means of a letter dated in May 2007 from the RO to the appellant, which was issued prior to the RO decision in November 2007. Additional letters were issued in March 2010, August 2011, October 2011, and January 2013. Those letters informed the appellant of what evidence was required to substantiate the claim and of her and VA's respective duties for obtaining evidence. The Board finds that the content of those letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. She was provided an opportunity at that time to submit additional evidence. In addition, the November 2011 and March 2013 SSOCs provided the appellant with an additional 60 days to submit additional evidence. Thus, the Board finds that the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her claim. It also appears that all obtainable evidence identified by the appellant relative to her claim has been obtained and associated with the claims file, and that neither she nor her representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. It is therefore the Board's conclusion that the appellant has been provided with every opportunity to submit evidence and argument in support of her claim, and to respond to VA notice. In connection with the current appeal, an appropriate VA medical opinion has been rendered and service treatment records, military personnel records, including deck logs, and post-service records have been obtained. We also note that the VA medical opinion was adequate. The clinician reviewed the history and the established clinical findings and presented reasons for his opinion. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim. The evidence of record provides sufficient information to adequately evaluate the claim, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained or requested. No further assistance to the appellant with the development of evidence is required. 38 U.S.C.A. § 5103A (a) (2); 38 C.F.R. § 3.159(d). II. Factual background. The record indicates that the Veteran served on active duty from January 1942 to November 1945. His service personnel records indicate that he served in the United States Navy, and was assigned to the USS Denver; his military occupational specialty was Seaman second class. The record reflects that the Veteran died in August 2006, at the age of 84. A copy of a certificate of death, dated August [redacted], 2006, shows that the Veteran's death was attributed to end-stage cardiac disease. No autopsy was performed. At the time of the Veteran's death, service connection was in effect for PTSD, rated as 50 percent disabling. The Veteran's service treatment records are negative for any complaints or findings referable to cardiovascular disease; and service records contain no mention of asbestos exposure. At discharge, clinical evaluation of his cardiovascular system was normal. Of record is a medical statement from Dr. Michael Kelly, dated in October 1998, indicating that the Veteran had a history of cardiac and respiratory difficulties. It was noted that the Veteran's respiratory problems had been present for some time. It was reported that the Veteran had worked at the Grey Iron Foundry from 1947 to 1948 and then at the Malleable from 1948 to 1980. He worked as a core maker and as a hot metal crane operator. The Veteran described ongoing exposure to a variety of fumes, smokes, dusts and other parituclates with significant exposure to asbestos and limited use of respiratory protection. Dr. Kelly also reported that the Veteran smoked cigarettes for about 50 years; he smoked about 3/4 of a pack a day. He discontinued the use of cigarettes in 1987. The impressions were asbestosis, coronary artery disease, and osteoarthritis. The examiner stated that there was sufficient laboratory and clinical evidence to establish a diagnosis of asbestosis. He further stated that the diagnosis was based upon the long history of exposure to asbestos and asbestos-related products, as well as the signs and symptoms of chronic lung disease, namely shortness of breath and crackling on chest examination. Dr. Kelly stated that, given the total clinical picture, there was a severe amount of impairment. Received in September 2005 was a copy of the Deck Log of the USS Denver indicating that the Seaman's duties when under attack were often not related to primary duties, and that the Veteran was involved in numerous bombardment campaigns where the ship suffered repeated damage. It was argued that the Veteran would have been exposed to asbestos when the ship, including the engine room, was damaged. Of record is a lay statement from A.M. E., the Veteran's daughter, dated in April 2006, indicating that her father was exposed to asbestosis during World War II while on board the USS Denver 58. She stated that there was asbestos all over that ship and not just in the engine room. A.M.E. noted that her father's ship was hit by a torpedo, which disturbed the asbestos and sent it flying through the ship. A.M.E. dated that while her father did work in the foundry later on and was exposed to more asbestos, his condition was far worse than the men he worked with in the plant. She argued that his condition was much more severe because of his previous exposure to asbestos in the Navy. The appellant's claim for service connection for the cause of the Veteran's death (VA Form 21-534) was received in October 2006. Submitted in support of the claim were treatment reports from Saint Mary's Hospital dated from January 2004 to May 2005. These records show that the Veteran received treatment for a respiratory disorder and heart disease, including congestive heart failure. A hospital summary, dated in January 2004, reflects final diagnoses of acute exacerbation of chronic bronchitis, severe chronic obstructive pulmonary disease/emphysema, coronary artery disease, status post coronary artery stent placement, pulmonary hypertension, and history of asbestosis. In March 2005, the Veteran underwent myocardial perfusion study which revealed a small but significant apical inferior wall and LV apex ischemia. He subsequently underwent a left cardiac catheterization. In May 2005, he was treated for acute dyspnea. At a personal hearing in June 2009, the appellant maintained that the Veteran's death was caused by his exposure to asbestosis while aboard the Denver Cruiser. She stated that the ship went to nine major battles, and there was asbestos all through the ship. The appellant maintained that while the Veteran later was in contact with asbestos in the foundry, he was worse than the other people who worked at the foundry as long as he did. She stated that the Veteran reported sleeping in bunks with pipes running over his bed and the dust present all around which he later learned was asbestos. The appellant indicated that while the death certificate listed end state cardiac disease as the cause of the Veteran's death, the lung and heart disease went together. The appellant also maintained that the end-stage cardiac disease was caused by his service-connected PTSD. Submitted in support of the appellant's claim was a medical statement from Dr. K. K. Ravindran, dated in July 2009, indicating that it was his opinion that the Veteran's PTSD may have caused and/or aggravated his heart disease beyond the nature of progression of the disease. Dr. Ravindran stated that the PTSD may have caused the Veteran to be a chain smoker, which was potentially harmful to his cardiac condition. He noted that the Veteran died as consequence of severe ischemic cardiomyopathy. In March 2010, the Veteran's claims file was referred to a VA examiner for review and opinion regarding the cause of his death. The examiner opined that the Veteran's end-stage cardiac disease was not caused by or aggravated by the Veteran's service-connected PTSD. The examiner noted that the Veteran died at the age of 84 on August [redacted], 2006; he also noted that the death certificate reflected that the cause of death was due to or as a consequence of end stage cardiac disease, manner of death was natural. He noted that PTSD was not evidenced in the death certificate as a contributing factor or aggravating cause in the Veteran's death. The VA examiner further noted that the military discharge physical of November 27, 1945, was normal. Moreover, the examiner stated that a review of all available medical records did not substantiate a causal relationship between PTSD and end stage cardiac disease. In July 2011, the Veteran's claims file was again referred to another VA examiner for review and opinion. The examiner opined that asbestosis was not a contributory cause of the Veteran's death. The examiner noted that there was no evidence of record to substantiate a diagnosis of asbestosis. The discharge physical dated in November 1945 noted that the Veteran was found to be physically qualified for honorable discharge by reasons of expiration of enlistment. The examiner explained that the death certificate stated that the cause of death was due to or as a consequence of end stage cardiac disease. He further noted that medical records from the Veteran's private physician, dated July 15, 2009, related that "he died as a consequence of severe ischemic cardiomyopahty. The Veteran's private physician did not substantiate a history of asbestosis in the past medical history of the Veteran as recent as 15 months prior to the Veteran's death. The examiner further noted that the Veteran had a history of tobacco abuse; and, a nexus between tobacco abuse and chronic obstructive pulmonary disease was well substantiated in the medical literature. The examiner further noted that on January 26, 2004, the Veteran's private physician listed a clinical impression of asbestosis; however, this impression was not substantiated by medical fact. The death certificate listed the Veteran's usual occupation as "Hot Metal Crane operator, Kind of business-Automotive Foundry." There were no records to substantiate that there was a potential relationship between asbestosis as a contributory cause of death and a potential relationship to asbestos exposure in Naval service in World War II as evidenced by the aforementioned facts. The examiner stated that he did not know the environmental conditions of a hot metal crane operator in an automotive foundry at the time the opinion was written. Received in August 2011 was an article regarding asbestos exposure in Navy Veterans. Received in October 2011 were treatment reports from St. Mary's Medical Center, dated from July 1994 to November 2005. These records show that the Veteran received ongoing clinical attention for heart disease and respiratory disorders since July 1994. A hospital summary dated in August 1994 indicates that the Veteran was admitted with a diagnosis of severe sinus bradycardia; during his hospitalization, he underwent a permanent pacemaker. The discharge diagnoses were sick sinus syndrome and history of smoking. A chest X-ray performed in April 2001 revealed chronic interstitial fibrotic lesions in both lung bases, without any evidence of acute pulmonary disease. In May 2003, the Veteran underwent a left heart catheterization and coronary angiogram. The Veteran was admitted to an emergency room in April 2004 with complaints of increasing shortness of breath and wheezing; the final diagnosis was chronic obstructive pulmonary disease exacerbation, with no evidence of pneumonia. In March 2005, the Veteran left heart catheterization stent placement. Subsequently received in November 2011 were treatment reports from Covenant Healthcare, dated from April 2001 to November 2003, reflecting treatment for a respiratory disorder and cardiovascular disease. In a consultation report, dated in August 2001, it was noted that the Veteran had been diagnosed as having asbestosis several years earlier; he apparently went through a class action lawsuit and was seen in Lansing and qualified for benefits due to asbestosis. It was noted that he worked at the Foundry and in World War II around ships. He also had been a heavy smoker, two packs per day. It was also reported that the Veteran had coronary artery disease, and had had a stent placed. The impressions were exacerbation of chronic obstructive pulmonary disease; acute bronchitis, pending review of chest x-ray; history of heavy smoking in the past; history of asbestosis; and history of coronary artery disease and left ventricular dysfunction. Also received in November 2011 were treatment reports from St. Mary's hospital dated from May 2005 to November 2005. These records show that the Veteran continued to receive clinical attention and treatment for heart disease, variously diagnosed. In February 2013, the Veteran's claims file was referred to a VA examiner for review and opinion regarding the cause of his death. Following a review of the claims file, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The examiner cited to the letter written by the Veteran's private physician dated in October 1998. The examiner noted that the Veteran worked in the foundry for 33 years after his discharge from service. It was noted that he had been in the Navy from January 1942 to November 1945; wherein he was a machinist. The examiner further noted that, as a civilian, the Veteran was a foundry worker for 33 years; during that time, he was a core maker and a hot metal crane operator with ongoing exposure to a variety of fumes, smokes, dusts and other particulates with significant exposure to asbestos and limited use of respiratory protection. As opposed to active service, there was no evidence to substantiate any exposure to asbestos; and, discharge physical, dated in November 1945, evidences a normal physical examination. The examiner observed that the medical records substantiate that the Veteran was exposed to asbestos for 33 years as a foundry worker. Therefore, the examiner stated that the Veteran's cause of death was not caused by or contributed to by the asbestosis. He explained that the Veteran's death certificate listed the cause of death as end-stage cardiac disease. The examiner further noted that the Veteran had a very significant history of tobacco abuse, smoking 3/4 pack of cigarettes a day for 50 years. He stated that there is no medical nexus to establish causality between asbestosis and end-stage cardiac disease. III. Legal Analysis. The appellant contends that service connection is warranted for the cause of the Veteran's death. Service connection may be awarded for a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"--the so- called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Holton v. Shinseki, 557 F.3d 1362 (2009). Service connection basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303 (2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). In addition, certain chronic diseases, including cardiovascular disease, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The death of a Veteran will be considered as having been due to a service-connected disability when such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). The service-connected disability will be considered the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). The service-connected disability will be considered a contributory cause of death when it contributed so substantially or materially to death, that it combined to cause death, or that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c) (1). The debilitating effects of a service-connected disability must have made the Veteran materially less capable of resisting the fatal disease or must have had a material influence in accelerating death. See Lathan v. Brown, 7 Vet. App. 359 (1995). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In such a situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c) (3), (4). With asbestos-related claims, VA must determine whether military records demonstrate asbestos exposure during service, and, if so, determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1, Part VI, 7.21(d) (1). The most common disease is interstitial pulmonary fibrosis (asbestosis). Asbestos fibers may also produce pleural effusions and fibrosis, pleural plaques, and mesotheliomas of pleura and peritoneum, lung cancer and cancers of the gastrointestinal tract. M21- 1, Part VI, 7.21(a) (1). The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1, Part VI, 7.21(c). Some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, military equipment, etc. M21-1, Part VI, 7.21(b)(1). The relevant factors discussed in the manual must be considered and addressed by the Board in assessing the evidence regarding an asbestos related claim. However, the pertinent parts of the manual guidelines on service connection in asbestos-related cases are not substantive rules, and there is no presumption that a Veteran was exposed to asbestos in service. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed.Cir. 2002); VAOPGCPREC 4-2000. Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d. 1372 (2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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 (West 2002 & Supp. 2012). Upon careful review of the evidentiary record, the Board finds no competent evidence which establishes the onset of the fatal disease process, end-stage cardiac disease, during the Veteran's active service. The service treatment records are negative for any complaints, diagnosis of or treatment for a cardiovascular disease. Rather, at separation, the cardiovascular system was normal. Moreover, there is no indication of any cardiovascular disease within one year after service. Therefore, end-stage cardiac disease, which led to the Veteran's death, may not be presumed to have been incurred during his active service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Significantly, the post-service medical records show that cardiovascular disease was first diagnosed in August 1994, approximately 49 years after the Veteran's discharge from service. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that a lapse of many years after the events in question during service and the initial manifestation of symptoms after service is probative evidence to be considered in deciding a service-connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). It follows that there is no basis to award service connection based on chronicity in service or continuous symptoms thereafter. 38 C.F.R. § 3.303(b). In addition, the presumption of in-service incurrence for a cardiovascular disease seen within one year of service is not for application. 38 U.S.C.A. § 1112(a) (1); 38 C.F.R. § 3.307(a) (3). Moreover, the Board finds that the record does not contain competent evidence to establish a nexus, or link, between the underlying cause of death, end-stage cardiac disease, and the Veteran's active service. Furthermore, following a review of the Veteran's claims file, in March 2010, a VA examiner opined that the Veteran's end-stage cardiac disease was not caused by or aggravated by his service-connected PTSD. The examiner noted that PTSD was not evidenced in the death certificate as a contributing factor or aggravating cause in the Veteran's death. The VA examiner further noted that the discharge physical of November 27, 1945, was normal. Moreover, the examiner stated that a review of all available medical records does not substantiate a causal relationship between PTSD and end stage cardiac disease. In light of the foregoing, the Board finds that the fatal disease, which led to the Veteran's death, was not present in service or manifest to a compensable degree within one year after separation from service. In fact, as noted above, a cardiovascular disease was not medically shown until 1994, many years following the Veteran's separation from military service. Thus, service connection would not be warranted for the terminal conditions either on the basis of direct service incurrence or on the basis of having become manifest to the required degree within one year following the Veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Again, there is no medical evidence of cardiovascular disease during service, and no records tending to suggest that the Veteran was treated for or diagnosed with this condition any earlier than 49 years after service. The examiner further noted that the Veteran had a very significant history of tobacco abuse, smoking 3/4 pack of cigarettes a day for 50 years. The examiner stated that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The appellant has also advanced contentions to the effect that the Veteran was exposed to asbestos during service, and that his led to the development of the disorder which caused his death. However, there is no indication in the record that the Veteran was exposed to asbestos in service, as the appellant contends; or that even if asbestos exposure took place, that this caused the Veteran's death. While the record indicates that the Veteran did serve aboard a ship while in the Navy, his service personnel records do not show that the Veteran had a major occupation typically involving exposure to asbestos. There is no presumption that a Veteran was exposed to asbestos in service by reason of having been aboard a ship. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); VAOPGCPREC 4-2000. In addition, the Board has considered the fact that the evidence of record indicates that the Veteran was diagnosed with asbestosis by a private doctor in October 1998, and a chest X-ray performed in April 2001 revealed chronic interstitial fibrotic lesions in both lung bases, without any evidence of acute pulmonary disease. The records also reflect a diagnosis of chronic obstructive pulmonary disease. However, as noted above, there is no evidence of asbestos exposure in service. Rather, the examiner noted that the Veteran worked in a foundry for 33 years after his discharge from the service; he further noted that, during that time, he was a core maker and a hot metal crane operator with ongoing exposure to a variety of fumes, smokes, dusts and other particulates with significant exposure to asbestos and limited use of respiratory protection. The examiner observed that the medical records substantiate that the Veteran was exposed to asbestos for 33 years as a foundry worker. Significantly, following a thorough review of the Veteran's claims file, in February 2013, a VA examiner opined that the Veteran's cause of death was not cause by or contributed to by the asbestosis. He explained that the Veteran's death certificate listed the cause of death as end-stage cardiac disease. The examiner further noted that the Veteran had a very significant history of tobacco abuse, smoking 3/4 pack of cigarettes a day for 50 years. He stated that there is no medical nexus to establish causality between asbestosis and end-stage cardiac disease. In addition, the Board has considered the appellant's claim that her father believed that his heart problems as well as his respiratory disorders were very likely caused by his exposure to asbestos while serving aboard ship in the Navy. Certainly, the Veteran was and the appellant is competent to report heart and respiratory symptoms, and her testimony in that regard is entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran and appellant, as laypersons, have not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as asbestosis or linking any post-service respiratory conditions and heart problems with any in-service exposure to asbestos. See Jandreau v. Nicholson, 492 F.3d 1372 (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). The Board finds such diagnoses especially problematic given that the onset of the Veteran's heart problems was following a 50 year history of smoking 3/4 pack of cigarettes daily and over 33 years working as a civilian at a foundry working around fumes, smokes, dusts and other particulates with significant exposure to asbestos and limited use of respiratory protection. As such, given the complexity of the diagnoses and facts of the case the Board concludes that the appellant is not competent to link end-stage cardiac disease or any other disability to asbestos exposure. In addition to the contentions addressed above, the appellant has asserted that the Veteran's service-connected PTSD substantially and materially contributed to his cause of death. Information in the claims file shows that the Veteran was granted service connection for PTSD in February 2006 and assigned a 50 percent evaluation effective September 30, 2005. Medical evidence of record shows treatment for PTSD. However, there is no persuasive evidence that the Veteran's PTSD contributed substantially or materially to death, or combined to cause death, or aided or lent assistance to the production of his death. It is noteworthy that the appellant submitted an opinion from Dr. Ravindran, dated in July 2009, who stated that "the PTSD may have caused the Veteran to be a chain smoker, which was potentially harmful to his cardiac condition." However, the Court has held that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible: and "it is within the realm of medical possibility" too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical opinion framed in terms of "may or may not" is speculative and insufficient to support an award of service connection for the cause of death). By contrast, following a review of the claims folder in March 2010, a VA examiner noted that PTSD was not evidenced in the death certificate as a contributing factor or aggravating cause in the Veteran's death. The VA examiner stated that a review of all available medical records does not substantiate a causal relationship between PTSD and end stage cardiac disease. Furthermore, to whatever extent the appellant has attempted to herself link the Veteran's service connected PTSD to the causes of his death due to end-stage cardiac disease, as a layperson without the appropriate medical training and expertise, she is not competent to offer a probative opinion on such complex medical matters. Although lay persons are competent to provide opinions on some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), diagnosing and identifying the etiology of the bilateral shoulder and left arm conditions here at issue 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). Accordingly, however well meaning, to whatever extent the assertions of the appellant are being advanced to establish a medical relationship between the Veteran's death and either service or service-connected disabilities, such evidence must fail. Matters of diagnosis of disabilities not capable of lay observation, and the medical etiology of any such disability, are matters within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As a layperson not shown to possess appropriate medical training and expertise, the appellant is not competent to render a persuasive opinion on any medical matter upon which this claim turns. See, Bostain v. West, 11 Vet. App. 124, 127 (1998. Simply stated, the determination as to the cause of the Veteran's death is a complex medical question for which the appellant lacks adequate medical training to answer. See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, any lay assertions in this regard have no probative value. Given the above, there is no evidence of a nexus between the Veteran's service connected PTSD and his end-stage cardiac disease; nor is there competent evidence showing that the fatal disease processes were related to any incidence of service. Therefore, the preponderance of the evidence is against the claim of service connection for the cause of the Veteran's death. As there is not an approximate balance of positive and negative evidence regarding the merits of the appellant's claim that would give rise to a reasonable doubt in favor of the appellant, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). In light of the foregoing, the evidence weighs against the appellant's claim of entitlement to service connection for the cause of the Veteran's death, and the appeal must be denied. ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs