Citation Nr: 1330909 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 09-41 622 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESSES AT HEARING ON APPEAL The appellant and her daughter ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from February 1958 to June 1962, and August 1962 to October 1979. He died in January 1999. The appellant is the Veteran's surviving spouse. This matter comes to the Board of Veterans' Appeals (Board) from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, which denied entitlement to service connection for the cause of the Veteran's death. In June 2012, the appellant testified before the undersigned Veterans Law Judge at a Board video conference hearing at the RO. This case was previously before the Board in November 2012, at which time the Board remanded the case for additional development. Specifically, the RO was directed to provide a medical opinion addressing the appellant's claim, and to make efforts to obtain copies of treatment records from the San Diego Naval Medical Center and La Jolla VA Medical Center from 1978 to 1979. The directives of the Board's remand have been substantially complied with. The case is now returned for appellate review. FINDINGS OF FACT 1. The Veteran died in January 1999; the death certificate reflects that the immediate cause of the Veteran's death was cardiopulmonary arrest due to intra cerebral hemorrhage, spontaneous, non-traumatic, with no other significant conditions contributing to death. 2. At the time of the Veteran's death in January 1999, he was not service connected for any disabilities. 3. The medical evidence establishes that the hypertension that substantially contributed to the death of the Veteran was not incurred in service, and establishes that no other disabilities related to service caused, contributed to, or accelerated death. CONCLUSION OF LAW The criteria for entitlement to service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1310, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013)), imposes obligations on the VA in terms of its duty to notify and assist claimants. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); 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 claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice must be provided prior to the initial unfavorable adjudication by the RO. Id. at 120. VCAA notice requirements apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, section 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 at the time of his or her death; 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). While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a predecisional adjudication of the claim prior to providing a section 5103(a)-compliant notice. Here, the duty to notify was satisfied by way of letters dated in March 2008 and January 2010 that fully addressed all notice elements. The claim was subsequently readjudicated in a July 2013 supplemental statement of the case, thereby curing any timing defect of the notice. The appellant was notified of the criteria for substantiating the service connection claim for the cause of the Veteran's death. As the Veteran was not service-connected for any disabilities during his lifetime, notice of service-connected disabilities is inapplicable to the Veteran's claim. The appellant has received all essential notice, has had a meaningful opportunity to participate in the development of her claim, and is not prejudiced by any technical deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Next, VA has a duty to assist the appellant in the development of the claim. This duty includes assisting her in the procurement of service treatment records and pertinent post-service treatment records and providing an opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Regarding the duty to assist, VA obtained the Veteran's service treatment records, VA treatment records dated from 1998 to 1999 up to the Veteran's death, records from the San Diego Naval Medical Center dated from 1984 to 1988 and from 1994 to 1997, and private treatment records dated from 1998 to 1999 prior to the Veteran's death. The Board notes that the appellant has reported (in a VA Form 21-4142 submitted in April 2008, as well as in her testimony in June 2012) that the Veteran was treated at the Naval Medical Center San Diego ("Balboa"), starting in 1978, including for high blood pressure. The appellant also testified that the Veteran received treatment at the La Jolla VA Medical Center in 1978 - 1979. However, of record are treatment records from the Naval Base Coronado dated from 1984 to 1988, and from the Naval Medical Center San Diego from 1993 to 1998. There are no treatment records for the Veteran from the Naval Medical Center San Diego or Coronado dated prior to September 1984; nor are there treatment records from the La Jolla VAMC dated from 1978-1979. In November 2011, the RO made a formal finding of unavailability of records from the Naval Medical Center San Diego from 1978 to 1996. Therein, as well as in the claims folder, it is clear that the Naval Medical Center San Diego advised that the Veteran's records had been retired to the National Personnel Record Center (NPRC). Thereafter, requests were made to the NPRC, via letters and then via PIES (Personnel Information Exchange System), requesting the Veteran's retired medical records dated from 1980 through 1996. Although, the RO noted that a PIES response was received from the NPRC in October 2008, such response had not been associated with the claims folder. In addition, it appears that a request for the Veteran's "retired" records, dated specifically back to 1978 had not been made. Thus in light of the appellant's testimony and statements regarding the Veteran's treatment dated back to 1978, the Board remanded this case in November 2012 for a request for such records. Thereafter the RO requested records from the Naval Medical Center in San Diego dating back to 1978 from the NPRC. The NPRC responded that all service treatment records had been mailed. In November 2012, the RO requested copies of treatment records in the archives if necessary from San Diego VAMC (which includes La Jolla VAMC). The RO made another request for archived records to the San Diego VAMC in March 2013. In response a January 1999 treatment record from the San Diego VAMC was provided (which was already of record). The RO notified the appellant of its unsuccessful attempts to obtain the treatment records from the La Jolla VAMC in April 2013. In May 2013, the RO made a formal finding of unavailability of 1978 to 1979 medical records at the La Jolla VAMC. In April 2013, the appellant submitted a statement that the Veteran was still on active duty stationed in North Island Naval Station in Coronado, CA from 1978 to 1979. She stated that he reported to the North Island Clinic concerning his blood pressure and tried to get it down by exercising. The RO subsequently requested records of active duty inpatient treatment for hypertension from the Naval Medical Center in San Diego from January 1978 to December 1978; but the NPRC responded that no such records were located. In July 2013 the RO sent the appellant a letter noting its unsuccessful attempts at obtaining records from the Naval Medical Center in San Diego for 1978. The RO also made a formal finding of unavailability for clinical records from the Navy Medical Center in San Diego dated in 1978. Based on the responses received from the NPRC and the VAMC in San Diego, it appears that all available records have been added to the file and that any further attempts to obtain records dated back to 1978 at these facilities would be futile. The RO also provided the appellant with a VA medical opinion in December 2012. The report obtained contains sufficient information to decide the issue on appeal and further examination is not necessary. See Massey v. Brown, 7 Vet. App. 204 (1994). The appellant has been afforded a hearing before the undersigned Veterans Law Judge (VLJ) in which she presented oral argument in support of her service connection claim for the cause of the Veteran's death. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ or DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the elements that were lacking to substantiate the claim. The VLJ also asked specific questions directed at identifying the criteria for service connection and sought to identify any pertinent evidence not currently associated with the claims, including more details pertaining to the Veteran's alleged treatment for hypertension right after his separation from military service. The appellant also volunteered the Veteran's treatment history and symptoms since service. Neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the appellant, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the appellant by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the appellant in adjudicating this appeal. II. Entitlement to Service Connection for Cause of Death The appellant seeks service connection for the cause of the Veteran's death. She contends that the cause of the Veteran's death is related to service, and has advanced two etiological theories as to the cause of the Veteran's death. One theory (espoused in her substantive appeal) is that the Veteran's death was caused by his time in the Navy when he was a machinist mate and dealing with asbestos on a continuing basis. The other theory, advanced by the appellant through her testimony and by her representative in a statement (VA Form 646), is that the Veteran's death was linked to his cardiovascular disease, including hypertension and heart problems, which they contend had an onset during his active service and for which they contend he was prescribed medication for just after his separation from active service. Service connection for the cause of the veteran's death may be granted if a disability incurred in or aggravated by service was either the principle, or a contributory, cause of the veteran's death. 38 C.F.R. § 3.312(a). For a service-connected disability to be the principle cause of death it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. 38 C.F.R. § 3.312(b). For a service-connected disability to be a contributory cause of death it must have contributed substantially or materially, and combined to cause death. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312(c)(1). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; 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. "Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death." 38 C.F.R. § 3.312(c)(3). Generally, minor service-connected disabilities, particularly those of a static nature, or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. 38 C.F.R. § 3.312(c)(2). "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 this 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)(4). Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that proof of direct service connection may entail proof that exposure during service caused the malady that appeared many years later); Cosman v. Principi, 3 Vet. App. 503, 505 (1992) (holding that service connection can still be established even when a Veteran did not have a particular condition diagnosed during service or for many years thereafter). In order to establish service connection, the evidence must generally 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. Alternatively, under 38 C.F.R. § 3.303(b), the second and third Shedden/Caluza elements can be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing inservice incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). In this case hypertension is considered a chronic disability under 38 C.F.R. § 3.309(a). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. Symptoms, and not treatment, are the essence of any evidence of continuity of symptomatology. Savage, 10 Vet. App. at 496. The third Barr/Savage element is not equivalent to the third Shedden/Caluza element, as requiring medical nexus evidence under 38 C.F.R. § 3.303(b) would nullify that regulation. Id. at 497. However, it does not follow that any present disability is necessarily related to any demonstrated continuous symptomatology. Id. Therefore, in Savage, the Court held that competent evidence is required to demonstrate a relationship between the continuous symptoms and the presently diagnosed disability. Id. (explaining that "medical evidence is required to demonstrate such a relationship unless such a relationship is one to which a layperson's observation is competent"). 38 U.S.C.A. § 1154(a) requires VA to give "due consideration" to "all pertinent medical and lay evidence" when evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Generally, the Board should determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). "Sometimes 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." Jandreau, 492 F.3d at 1377, n4. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lastly, a layperson may also be competent to testify to the manifestations of a chronic condition during service or a presumptive period or to continuity of symptomatology. Hickson, 12 Vet. App. at 253. Certain chronic disabilities, including hypertension, may be presumed to have been incurred in or aggravated by service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. There is no specific statutory or regulatory guidance with regard to claims for service connection for asbestos-related diseases. However, in 1988 VA issued a circular on asbestos-related diseases which provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular have since been included in VA Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (Oct. 3, 1997) (hereinafter "M21-1"). Subsequently, an opinion by the VA General Counsel discussed the development of asbestos claims. VAOPGCPREC 4-2000 (April 13, 2000). The Board notes that the aforementioned provisions of M21-1 were rescinded and reissued as amended in a manual rewrite (MR) in 2005. See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 29, entitled "Developing Claims for Service Connection for Asbestos-Related Diseases," and Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9, entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." The manual provisions acknowledge that inhalation of asbestos fibers and/or particles can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. As to occupational exposure, exposure to asbestos has been shown in insulation and shipyard workers, and others. M21-1MR, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9a-f. The manual further provides that VA must determine whether military records demonstrate evidence of asbestos exposure in service, and whether there is pre-service and/or post-service evidence of occupational or other asbestos exposure; and then make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the Veteran. M21-1MR, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9h. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Turning now to the facts of this case, the record reflects that the Veteran died in January 1999. His death certificate indicates that the immediate cause of death was cardiopulmonary arrest (time interval between onset and death: 5 minutes) due to intracerebral hemorrhage, spontaneous, nontraumatic (time interval between onset and death: 2 months). At the time of the Veteran's death, service connection was not in effect for any disabilities. Service treatment records are negative for any findings pertaining to the Veteran's death. His multiple blood pressure readings were mostly within the normal range There was an elevated blood pressure reading in July 1974 (130/90) and in July 1975 (148/98). However, there were no findings consistent with hypertension. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm, or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm, or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1), under Diseases of the Arteries and Veins. These must be confirmed by readings taken two or more times on at least three different days. Id. There also is no record of treatment with hypertension medication in the service treatment records. The Veteran's separation examination in September 1979 shows a normal examination of the heart with a blood pressure reading of 122/82. On the Report of Medical History at the time of separation, the Veteran denied ever having or having then a history of high blood pressure. Post-service medical records show that in September 1984 the Veteran was noted to have elevated blood pressure and the diagnosis was early hypertension. Additionally, the findings on a chest x-ray dated in February 1993 were consistent with previous asbestos exposure. At the time of the Veteran's admission to the hospital in October 1998, prior to his death, it was noted that the Veteran had hypertensive hemorrhage with resultant hydrocephalus. As noted the Veteran later died in January 1999 due to cardiopulmonary arrest, due to spontaneous non-traumatic intracerebral hemorrhage. A VA medical opinion was provided in December 2012 to address the appellant's two theories of entitlement to service connection for the cause of the Veteran's death; one, that his exposure to asbestos in service caused his death; and two, that he had hypertension onset during his military service that later caused his death. The examiner reviewed the Veteran's claims file and noted the Veteran's cause of death with no other significant conditions leading to death. It was noted that the Veteran was at risk during service for asbestos exposure and subsequent chest x-ray after service showed that he had pleural plaque, evidence of pulmonary involvement from asbestosis, but that he did not have a known lung tumor or malignancy. The examiner determined that the Veteran's asbestosis of the lungs was more likely than not incurred in or related to service. The examiner found, however, that while rare, the only possible way for asbestosis to cause a brain hemorrhage would be for there to be a lung cancer from the asbestosis, with metastatic tumor to the brain and secondary hemorrhage. The examiner further noted that for this to be the cause there would have had to be a tumor in the lung and seen on chest x-ray, and in the brain, seen on imaging at that time or post mortem. The examiner determined that since there was no documented tumor in the lung or brain, and since the death certificate listed the hemorrhage as spontaneous and not due to a tumor, it was less likely than not that the hemorrhage and death was related to the asbestosis, or that the asbestosis contributed substantially or materially to the Veteran's death; or combined to cause death, or aided or lent assistance to the production of death. With respect to the appellant's other theory of entitlement to service connection for cause of the Veteran's death, namely that the Veteran had hypertension related to his military service, which caused his death, the examiner noted that the Veteran's hypertension more likely than not contributed substantially to his death. It was noted that the most common cause of spontaneous intracerebral hemorrhage was chronic hypertension. With respect to whether the Veteran's hypertension was related to his military service, the examiner noted that there was no evidence of hypertension during or caused by service. The examiner indicated that the Veteran's separation physical in September 1979 was normal, without mention of hypertension and his blood pressure at the physical was normal at 122/82. The examiner further noted that the Veteran was not on medication for blood pressure at that time. The examiner acknowledged that while there was a single elevated blood pressure in July 1975 of 148/98, there was no indication that this represented hypertension, as blood pressures normally fluctuated from day to day, which was why hypertension was not diagnosed by a single reading. The examiner commented that there were no serial blood pressure readings recorded in the claims file. The examiner further determined that "since the separation physical reading is normal, and the veteran was not on medication, it would be less likely than not, indeed highly unlikely, for the veteran to have been hypertensive during service." Therefore, it was the examiner's opinion that the Veteran's hypertension was not incurred in or aggravated by his service. The examiner finally noted that there were no other significant medical conditions in the Veteran's service treatment records, or subsequent to it; thus, the examiner concluded that it was less likely than not that any other medical condition during his lifetime was incurred in or aggravated by his service. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's cause of death is not related to any event in service. In making this determination, the Board finds it significant that the only evidence of record indicating a possible nexus between the Veteran's cause of death and his military service are the appellant's assertions. The Board acknowledges that the appellant was married to the Veteran since 1977 and is competent to report that the Veteran was treated with medication for high blood pressure around the time of his separation from service in 1979 and soon after service. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The appellant is also competent to report that he suffered from high blood pressure in service and was given medication and told to exercise during active duty. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled, or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It is within the appellant's realm of personal knowledge whether the Veteran suffered from and took medication for high blood pressure in service and continued to experience high blood pressure since military service. However, while the appellant is competent to report her recollections and observations about the Veteran's history of high blood pressure, competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. The appellant's lay statements and testimony regarding the onset and treatment of the Veteran's hypertension must be viewed in conjunction with the objective medical evidence of record. And, the ultimate probative value of her lay testimony and statements is determined not just by her competency, but also her credibility to the extent her statements and testimony concerning this are consistent with this other evidence. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In this regard, the Board finds that when weighing the appellant's statements and testimony against the medical evidence of record, the preponderance of the evidence shows that hypertension was not established in service and that there was no continued symptomatology of hypertension from service until five years after his separation from service in 1984, when he was diagnosed with early hypertension. Thus, the Board has accorded her statements lesser probative weight in this case than the other evidence of record. As noted, the service treatment records only document two isolated findings of high blood pressure. These isolated findings do not establish that the Veteran had a chronic condition in service. The Veteran also denied any history of high blood pressure on the Report of Medical History at his separation from service in 1979. In addition the service treatment records at separation from service show a blood pressure reading in the normal range and make no mention of the Veteran being on medication for hypertension. Even though the appellant has made competent statements that the Veteran was put on medication for high blood pressure during his active duty service, this is not consistent with the service treatment records dated through his separation in 1979, which do not show any findings of chronic high blood pressure or hypertension diagnoses, and make no mention of the Veteran being on medication for high blood pressure. Also, while the appellant is competent to relay what a doctor told the Veteran regarding hypertension, she is not competent to render a diagnosis of hypertension. Thus, any continued symptoms of elevated blood pressure that she observed are not necessarily attributed to an underlying diagnosis of hypertension without medical evidence that establishes such a diagnosis which the Board finds would be required in this case where there is a complex medical question at issue. The appellant contends that the Veteran's cause of death is related to his military service; however, there is no competent medical evidence or opinion to corroborate these contentions. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The appellant's opinions are insufficient to provide the requisite nexus between an in-service event or injury and any current disability because, as a lay person, she is not competent to establish a medical etiology merely by her own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512, 520 (2004); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (holding that a layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, her statements regarding the etiology of the Veteran's cause of death are merely speculation as to a possible cause as she is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to medical causation. The Board also finds it significant that a VA examiner in December 2012 found that after reviewing the claims file and pertinent medical history that the Veteran's cause of death was not related to military service. The rationale for the opinion was that the Veteran was only found to have one isolated reading of high blood pressure in service; and was found to have normal blood pressure at separation from service with no indication that he was on medication for hypertension. Thus, the examiner determined that it was highly unlikely that the Veteran was hypertensive during service. The examiner also found that while the Veteran had an asbestosis-related lung disease that was incurred in service, it was not related to the Veteran's cause of death, as the lung impairment had not resulted in lung cancer that metastasized to the brain with a tumor. The probative value of the December 2012 examiner's opinion is high as the examiner was fully informed of the Veteran's medical history, provided a fully articulated rationale, and the opinion was supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). While the examiner commented that there was only one elevated blood pressure reading in service, when there actually were two, the Board does not find that this undermines the probative value of the opinion, as the examiner determined that a finding of chronic high blood pressure would require multiple readings and could not be established by one reading on any given day. Presumptive service connection for hypertension is not warranted under 38 C.F.R. §§ 3.307, 3.309, as the medical evidence does not indicate that the Veteran had hypertension within one year of his separation from service. Notwithstanding the appellant's assertions that the Veteran was treated for high blood pressure with medication in service and within one year thereafter, the preponderance of the evidence shows that this was not the case. The medical evidence of record does not show a diagnosis of hypertension until 1984, which is 5 years after separation from service. Also, at that time it is significant that the Veteran's hypertension was considered early hypertension (rather than something that had necessarily been persisting for five years). The Veteran's cause of death is also not considered to be related to his exposure to asbestos in service, for the reasons given in the December 2012 medical opinion, namely that the asbestos-related lung disorder the Veteran had did not result in lung cancer that metastasized to the brain. In addition, none of the post-service medical evidence relates the Veteran's cause of death to his military service; so service connection under 38 C.F.R. § 3.303(d) is not warranted. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's cause of death is related to his military service. See 38 U.S.C.A. §§ 1110, 1131. Accordingly, the Board finds that the criteria for service connection for the cause of the Veteran's death are not met and the appellant's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). (Continued on the next page) ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs