Citation Nr: 1331832 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 09-32 100 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a bilateral hearing loss disability. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a left hip disability. 4. Entitlement to service connection for a skin disability, to include as due to Agent Orange exposure (originally claimed as rash of the legs and back). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran served on active duty from March 1968 to March 1971. This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Denver, Colorado Regional Office (RO). By that rating action, the RO denied service connection for a bilateral hearing loss disability, tinnitus, left hip disorder, and rash of the legs and back. The Veteran appealed this rating action to the Board. In May 2013, the Veteran testified before the undersigned Acting Veterans Law Judge (AVLJ) at a video conference hearing conducted via the above-cited RO. A copy of the hearing transcript has been associated with the claims files. The issues of entitlement to service connection for a left hip disorder and a skin disability (originally claimed as a rash of the legs and back), to include as due to Agent Orange exposure, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran served as a helicopter crew chief during military service in the United States Army, and was exposed to acoustic trauma from M60 machine guns during combat in the Republic of Vietnam (RVN). 2. The record contains competent medical and lay evidence indicating that the Veteran has a bilateral hearing loss disability according to VA standards, which is causally related to his military service. 3. The record also contains competent medical and lay evidence indicating that the Veteran has bilateral tinnitus, which is causally related to his military service CONCLUSIONS OF LAW 1. Bilateral hearing loss disability was incurred in active military service and service connection for this disability is warranted. 38 U.S.C.A. §§ 1110, 1131, 1154(a), (b), 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. Resolving all reasonable doubt in the Veteran's favor, the Veteran's tinnitus was incurred in active military service and service connection for this disability is also warranted. 38 U.S.C.A. §§ 1110, 1131, 1154(a), (b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Given the favorable disposition of the Veteran's claims for service connection for bilateral hearing loss disability and tinnitus, the Board finds that all notification and development action needed to render a fair decision on these aspects of these claims has been accomplished. I. Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection in generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). 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. A preexisting injury or disease will be considered to have been aggravated by active 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. Clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertinent to the manifestation of the disability prior to, during and subsequent to service. Id. Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered 'aggravation in service' unless the underlying condition, as contrasted with symptoms, has worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993). Accordingly, 'a lasting worsening of the condition'--that is, a worsening that existed not only at the time of separation but one that still exists currently is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). To rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before the VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 03-2003 (July 16, 2003). In certain situations, a veteran's own statements that his current disorder or disease preexisted his active service may serve, even in the absence of verifying clinical evidence, as clear and unmistakable evidence sufficient to rebut the presumption of soundness. See Harris v. West, 203 F.3d 1347, 1350 (Fed. Cir. 2000), which noted that 38 U.S.C.A. § 1111 does not limit the kind of evidence that can be used to rebut the presumption of soundness to medical evidence, and, that 38 C.F.R. § 3.304(b) in fact notes the need to consider the history of pre-service conditions recorded at the time of examination and other evidence of record. If a pre-existing disorder is noted upon entry into service, the Veteran cannot bring a claim for service incurrence for that disorder, but the Veteran may bring a claim for service-connected aggravation of that disorder. In that case, the provisions of 38 U.S.C.A § 1153 and 38 C.F.R. § 3.306 apply, and the burden falls on the Veteran to establish aggravation. Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). An important distinction between section 1111's aggravation prong of the presumption of soundness and section 1153's presumption of aggravation is the burden of proof. Under section 1111, the burden is on the Government to show by clear and unmistakable evidence that there was no increase in disability in service or, that any increase was due to the natural progress of the disease. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Under section 1153, however, the Appellant bears the burden of showing that his preexisting condition worsened in service. Id. Once the veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease. Horn v. Shinseki , 25 Vet. App. 231, 235 (2012). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (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 v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). However, the Federal Circuit recently held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a), such as organic diseases of the nervous system and arthritis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. II. Merits Analysis (i) Bilateral Hearing Loss Disability The Veteran seeks service connection for a bilateral hearing loss disability. He contends that his current hearing loss is the result of acoustic trauma, such as M60 machine guns and jet engines, that he sustained while serving as a crew chief during military service. (Transcript (T.) at page (pg.) 3). He also maintains that he did not have any post-service noise exposure. Id. Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 hertz, in ISO units, is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2013). The United States Court of Appeals for Veterans Claims, citing Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992) stated in Hensley v. Brown, 5 Vet. App. 155 (1993), that it has held the above regulation, although prohibiting an award of service connection where audiometric test scores are within established limits, does not prevent a Veteran from establishing service connection on the basis of post-service evidence of hearing loss related to service when there were no audiometric scores reported at separation from service. See Hensley, supra (noting that a loss of 20 decibels or more could indicate some hearing loss, albeit not meeting the thresholds of 38 C.F.R. § 3.385 )). The Veteran's February 1968 enlistment examination report reflects that an audiogram at service entrance contained an auditory threshold of 20 at 4000 Hertz right ear. These findings are not consistent with the findings necessary to establish a hearing loss disability for VA benefits purposes. The Board also notes that these findings were not otherwise supported by a diagnosis of hearing loss disability in either ear. Thus, the Board finds that presumption of sound condition at service entrance does attach with respect to both ears, and his claim of entitlement to service connection for hearing loss disability is one of direct service connection. See Crowe v. Brown, 7 Vet. App. 238, 245 (1994); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.306 . The Board finds that the Veteran has a bilateral hearing loss disability according to VA standards during the appeal period. In this regard, a November 2008 VA audiological evaluation report reflects that the Veteran scored 75 and 80 Hertz at 3,000 and 4,000 decibels. A January 2011 VA audiological evaluation report uploaded to the Veteran's Virtual VA claims files reflects that he scored 45 Hertz at 3,000 and 4,000 Hertz in the left ear. Thus, the question that remains in this case is whether the evidence of record supports a finding that the Veteran's bilateral hearing loss disability for VA compensation purposes had its onset during military service or is etiologically related to an incident or event therein. The Board finds that the medical evidence of record supports the Veteran's contention that he has a bilateral sensorineural hearing loss disability that is causally related to noise exposure he experienced in service. The Veteran has reported, in both testimony and in written statements, a history of military noise exposure due to service, and his DD Form 214 states that the Veteran's military occupational specialty was a helicopter crew chief. He served in the RVN from September 19, 1968, to September 18, 1969. According to the Veteran's service personnel records, he received, in part, the Air Medal (First Oak Leaf Cluster) for heroism while serving as a door gunner aboard a helicopter in the RVN. According to the Veteran, he had in-service noise exposure from M60 machine guns and jet engine noise while he was serving as a helicopter crew chief and from combat in the Republic of Vietnam without the benefit of hearing protection. In view of the Veteran's DD 214 reflecting that he served as a helicopter crew chief, his confirmed RVN service and credible testimony before the undersigned, the Board finds that exposure to acoustic trauma in service is consistent with the circumstances of his service. 38 U.S.C.A. § 1154(a) and (b) (West 2002). As noted above, the Veteran's service treatment records show include a February 1968 enlistment examination report reflecting that an audiogram at service entrance contained an auditory threshold of 20 decibels at 4000 Hertz right ear. These findings are not consistent with the findings necessary to establish a hearing loss disability for VA benefits purposes. The Veteran's left ear did not show findings necessary to establish a hearing loss disability for VA benefits purposes. A November 1970 Annual Class III Flight Physical examination report reflects that the Veteran had a reading of 35 decibels at 4000 Hertz in the right ear. A February 1971 service separation examination report reflects that the Veteran had readings of zero in both ears from 1000-4000 Hertz with the exception of a reading of 5 in the left ear at 500 Hertz. On an accompanying Report of Medical History, dated in February 1971, the Veteran denied having had hearing loss, but indicated that he had ear, nose or throat trouble. On DA Form 3082-R, the Veteran related that there had not been any change in his medical condition since he was examined. (i.e., November 1970 Annual Class III Flight Physical). VA outpatient treatment records include an October 2008 audiology consult report reflecting that the Veteran had noticed difficulty hearing during the past ten years (1998), and constant tinnitus in both ears, which he described as a high-pitched ringing sensation that was louder in the right ear. He gave a history of a history of noise exposure to helicopters during service and denied any post-service noise exposure. The examiner diagnosed the Veteran with mild to profound and mild to moderate sensorineural hearing loss in the right and left ears, respectively. The examiner did not provide an opinion with respect to the etiology of the Veteran's hearing loss. When examined by VA in November 2008, the Veteran gave an in-service and post-service history with respect to his ears that is consistent with that previously reported herein. After an audiological evaluation, which revealed right hearing loss for VA compensation purposes (left ear hearing loss for VA compensation purposes was noted during a January 2011 VA audiological evaluation), the VA examiner indicated that the Veteran described having had tinnitus that warranted a diagnosis of that disability. The Veteran was diagnosed as having mild to profound mild to moderate right and left ear sensorineural hearing loss, respectively. The VA examiner opined that due to documented normal hearing at the time of the Veteran's discharge, it was her opinion that his current hearing loss and tinnitus were not due to military noise exposure. (See November 2008 VA audiological examination report). The November 2008 VA audiological examiner based her opinion, in part, on the absence of hearing loss at service separation and did not provide any reason why the Veteran's in-service acoustic trauma was not a source of his current bilateral hearing loss; the Board points out that the VA audiological examiner conceded that the Veteran had noise exposure during service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993) ("[§ 3.385] operates to establish when a measured hearing loss is...a 'disability' for which compensation may be paid, provided that the requirements for service connection are otherwise met..."). Further, in Hensley , the Court indicated that a veteran need not have met the requirements of 38 C.F.R. § 3.385 while in service, only presently. Hensley, 5 Vet. App. at 158-59. See also, Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The VA examiner's conclusory opinion based in part on the absence of documented hearing loss at discharge from service does not mean that there is no nexus between the Veteran's current hearing loss and his in-service noise exposure which lessens its probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that most of the probative value of a medical opinion comes from its reasoning). The Veteran has consistently and credibly contended, in written statements and in testimony, that in-service noise exposure caused his bilateral hearing loss disability and that it has continued until the present time. See Layno v. Brown, 6 Vet. App. 465 (1994). Moreover, the Board finds that the examiner's opinion regarding hearing loss was apparently based, in part, on an erroneous assumption that service connection for this condition required a documentary showing of hearing loss in service. The Veteran is also competent to observe the presence of bilateral hearing loss during and after his service and the Board finds his account of in-service onset of bilateral hearing loss to be additional probative evidence in support of his claim. The Veteran's statements as to his symptoms and experience additionally support a finding of both chronicity and continuing disability. Consequently, the competent and credible medical evidence of record supports the Veteran's claim for service connection for a bilateral hearing loss disability. The evidence in this case is at least in equipoise with regard to the cause of the Veteran's current bilateral hearing loss disability. Accordingly, service connection is warranted for the Veteran's bilateral hearing loss disability. (ii) Tinnitus Concerning the Veteran's claim of service connection for tinnitus, the Veteran has reported having had tinnitus since exposure to acoustic trauma during military service. (T. at pages (pgs.) 3, 4). At the above-cited November 2008 VA examination, the Veteran described having experienced constant tinnitus that began as a high pitch sound 15 years previously (1993) and a history of in-service acoustic trauma, as described above. He denied post-service recreational and vocational noise exposure. The VA November 2008 audiologist opined that the appellant's tinnitus loss was not due to military noise exposure, apparently based on the same erroneous presumption that a finding of tinnitus was necessary at the time of service separation. (See November 2008 VA audiological examination report). Therefore, under the particular circumstances presented here, and for essentially the same reasons articulated with respect to the Veteran's claim for service connection for hearing loss, the Board is persuaded that the Veteran' tinnitus can as likely as not be attributed to either the same etiology as his service-connected hearing loss, i.e., in-service exposure to noise, or directly to his service-connected hearing loss. The Board would also again note that the Board finds the Veteran to be credible and that his subjective complaints of tinnitus in service and at present are also credible. Thus, resolving all reasonable doubt in the appellant's favor, service connection for tinnitus is also warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a bilateral hearing loss disability is granted. Service connection for tinnitus is granted. REMAND For the reasons that follow the Board finds that the Veteran's claims for service connection for a left hip disorder and a skin disability (originally claimed as a rash on the legs and back), to include as secondary to Agent Orange exposure, must be remanded for further evidentiary development. Specifically, to schedule the Veteran for a VA examination and opinion as to the etiology of all currently diagnosed left hip and skin disabilities and to obtain outstanding VA treatment records. (i) VA examination First, with respect to his service connection claim for a left hip disorder, the evidence of record indicates that the Veteran has arthritis of the left hip/osteoarthritis of the left hip. Moreover, the Board finds the Veteran's contention that his left hip disability is the result of having served as a helicopter door gunner in numerous combat missions in Vietnam (at which time he would have to squat and thereby place an excessive amount of pressure on his hips, the left greater than the right), to include a mission wherein it was necessary to crash land as a result of enemy fire, are consistent with the circumstances of his service. In addition, since arthritis is a chronic condition under 38 C.F.R. § 3.309, consideration of his statements of continuity of symtomatology are warranted to determine whether service connection is warranted on this basis. Consequently, the Board finds that the Veteran should be provided with an appropriate examination to determine whether his left hip arthritis is related to his left hip injury during combat service. The Veteran further asserts that his skin disability is related to his presumed Agent Orange exposure. He maintains that during his final 13 days in the RVN, he was "shot down" into a patch of Agent Orange that was the size of a football field. He also maintains that his rashes are the result of exposure to "chemicals in the water" during service in the RVN. (T. at pg. 5). For purposes of establishing service connection for a disability resulting from exposure to an herbicide agent, a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, such as Agent Orange, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f), 38 C.F.R. § 3.307(a)(6)(iii). As noted in the decision above, the Veteran's service personnel records confirm his service in the RVN; thus, his ex exposure to Agent Orange is presumed. 38 C.F.R. § 3.307(a)(6). The Veteran's STRs are devoid of any subjective complaints or clinical findings relating to any skin pathology. A February 1971 service discharge examination report reflects that the Veteran's skin was evaluated as "normal." On an accompanying Report of Medical History, the Veteran denied having had skin diseases. VA and private medical records, dated from the late 1990s to 2012, contain diagnoses of tinea versicolor, viral exanthema, and questionable ptymosis rosea, and tinea cruris. The diseases subject to presumptive service connection as due to Agent Orange exposure include the following: chloracne or other acneform diseases consistent with AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes, Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2013). Recently, changes have been made to the regulation for presumptive service connection for veterans shown to have been exposed to Agent Orange. See 78 Fed. Reg. 54763 (September 6, 2013); 38 C.F.R. § 3.309(e). These changes replaced the term "acute and subacute peripheral neuropathy" with the term "early-onset peripheral neuropathy." VA also removed Note 2 to § 3.309(e), which had required, in order for the presumption to apply, that the neuropathy be transient and appear within weeks or months of exposure to an herbicide agent and resolve within two years of the date of onset. Under the amendments, peripheral neuropathy will still need to become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection, but it no longer needs to be transient. However, a presumption of service connection based on exposure to herbicides is not warranted for any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See 68 Federal Register 27630-27641 (May 20, 2003). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection for disability due to Agent Orange exposure with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Under 38 U.S.C.A. § 5103A(d)(2) (West 2002), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran has not been afforded a VA examination. In light of the assertions made by the Veteran regarding the onset of his claimed skin disability as due to his presumed Agent Orange exposure and his current skin diagnoses as noted above, the Veteran should be accorded a VA examination to address the etiology of skin conditions present, to include its relationship, if any, to his presumed Agent Orange exposure. 38 C.F.R. § 3.327 (2013). (ii) VA treatment records During the May 2013 hearing before the undersigned, the Veteran testified that a VA physician had recently received informed him that his skin disability could have been secondary to some type of defoliant or agent. The Veteran related that he was slated to return to the VA for a skin biopsy on his back in July (i.e., July 2013). (T. pgs. 6-7). While treatment records from the VA Medical Center (VAMC) in Denver, Colorado, dated through February 2012, have been associated to the claims files and thereafter uploaded to the Veteran's Virtual VA claims file, recent reports are absent. Thus, on remand, treatment records from the Denver, Colorado VAMC, dated from February 2012 to the present should be obtained and associated with the claims files or uploaded to the Veteran's Virtual VA electronic claims file. 38 U.S.C.A. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and obtain the names and addresses of all medical care providers, VA and non-VA, who have treated him for his left hip and skin disabilities since February 2012. Of particular interest, are VA treatment records, dated from February 2012 to the present, to include a July 2013 skin biopsy of his back and opinion from a VA physician that his skin disability could be the result of exposure to an in-service defoliant/agent as referenced by him during his May 2013 hearing. (T. at pg. 7). Any records obtained must be associated with the claims files. All attempts to procure records should be documented in the claims files. If the RO cannot obtain records identified by the Veteran, notations to that effect should be inserted in the claims files. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran an opportunity to obtain and submit those records for VA review. 2. After any additional records are obtained pursuant to the development in directive 1 is obtained and associated with the record, schedule the Veteran for VA joints examination by a qualified examiner. a. The claims files must be made available to and thoroughly reviewed by the examiner in connection with his or her respective examination, and the examiner must acknowledge such receipt and review in any report generated as a result of his or her examination. b. The examiner must review the Veteran's statements, hearing testimony, service and post-service treatment records in conjunction with the examination. Any special diagnostic studies deemed necessary should be performed. c. After reviewing the records, examining the Veteran, and identifying all appropriate symptoms and diagnoses, the examiner must provide medical findings or opinions responsive to the following question with respect to each left hip disability found on examination: d. Is it as least as likely as not (50 percent probability or greater) that any currently present left hip disability(ies) had its onset during military service or is etiologically related thereto, to include the the Veteran's service as a helicopter door gunner on numerous combat missions in Vietnam, which involved repeated squatting that affected the left hip more than the right? In reaching your opinion, you should also address the Veteran's statements of continuing left hip symptoms since service. A complete rationale must be provided for all opinions expressed. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. After any additional records are obtained pursuant to the development in directive 1 is obtained and associated with the record, schedule the Veteran for VA skin examination by a qualified examiner. a. The claims files must be made available to and thoroughly reviewed by the examiner in connection with his or her respective examination, and the examiner must acknowledge such receipt and review in any report generated as a result of his or her examination. b. The examiner must review the Veteran's statements, hearing testimony, service and post-service treatment records in conjunction with the examination. Any special diagnostic studies deemed necessary should be performed. c. After reviewing the records, examining the Veteran, and identifying all appropriate symptoms and diagnoses, the examiner must provide medical findings or opinions responsive to the following question with respect to each skin disability found on examination: d. Is it as least as likely as not (50 percent probability or greater) that any currently present skin disability(ies) had its onset during military service or is etiologically related thereto, to include the Veteran's presumed exposure to Agent Orange in the RVN? A complete rationale must be provided for all opinions expressed. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. After completing the requested action, and any additional notification and/or development deemed warranted, the RO/AMC must readjudicate the Veteran's claims for service connection for a left hip disorder and a skin disability (originally claimed as a rash on the legs and back) to include as due to Agent Orange exposures on appeal. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative a supplemental statement of the case and afford them an appropriate time period for response before the claims files are returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs