Citation Nr: 1335018 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 10-12 080 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for a chronic disability manifested by hypoglycemia. 2. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a hearing loss disability. 3. Entitlement to service connection for a hearing loss disability. REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from October 1962 to October 1966. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2008 rating decision of the RO in Providence, Rhode Island which denied the application to reopen the claim of entitlement to service connection for bilateral hearing loss and denied service connection for hypoglycemia. Although in an August 2011 supplemental statement of the case the RO ultimately reopened the claim of entitlement to service connection for bilateral hearing loss and adjudicated the claim on the merits, the Board must first examine whether the evidence warrants reopening the claim. This is significant to the Board because the preliminary question of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider the underlying claim on its merits. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996); see also Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001) (the Board does not have jurisdiction to review the claim on a de novo basis in the absence of a finding that new and material evidence has been submitted). In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. In an unappealed June 2005 rating decision, the RO denied service connection for bilateral hearing loss. 3. The evidence associated with the claims file subsequent to the RO's June 2005 rating decision includes evidence addressing the unestablished fact of whether there was an injury or disease in service; presuming this evidence to be credible, it is neither cumulative nor redundant of evidence already of record and it raises a reasonable possibility of substantiating the claim. 4. The Veteran's current hearing loss disability is not related to service, and was not manifested to a compensable level within one year of service separation. 5. There is no current chronic disability manifested by hypoglycemia. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for bilateral hearing loss are met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.156, 3.159 (2013). 2. A hearing loss disability was not incurred in service; an organic disease of the nervous system to include sensorineural hearing loss is not presumed to have been incurred in service. 38 U.S.C.A. §§ 337, 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2013). 3. The basic criteria for service connection for a chronic disability manifested by hypoglycemia are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Application to Reopen The RO initially denied a claim for service connection for bilateral hearing loss in a June 2005 rating decision. At the time of that decision, the medical evidence of record consisted of service treatment records and a VA examination report dated in April 2005. The Veteran's service treatment records reflected that, when examined for service enlistment in October 1962, both whispered voice testing and audiogram testing were conducted. The actual numeric values of the audiogram are not recorded on the examination form. An audiogram recording is stapled to the examination report; however, this card simply contains a zig-zag pen tracing across a pre-printed chart. The Board cannot reliably interpret the numeric values indicated by the pen tracing. Nevertheless, the October 1962 service examiner indicated on the examination form that the Veteran's ears (including auditory acuity) were clinically normal. In addition, the April 2005 VA examiner reviewed the results and also concluded that the Veteran's hearing was normal at enlistment. Prior to November 1967, audiometric results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization - American National Standards Institute (ISO-ANSI). In order to facilitate data comparison for VA purposes, ASA standards noted in service treatment records dated prior to November 1, 1967 must be converted to ISO-ANSI standards. The converted findings are in parentheses. In January 1963, audiometry was again conducted and pure tone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 (10) 0 (10) -10 (0) -5 (5) 5 (10) LEFT -5 (10) 0 (10) 5 (15) 15 (25) 15 (20) In January or June 1965, audiometry was conducted and pure tone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) LEFT 0 (15) 5 (15) 0 (10) 15 (25) 15 (20) In November 1965, audiometery was conducted and pure tone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 5 (15) 5 (15) 10 (20) 20 (25) LEFT 10 (25) 10 (20) 5 (15) 10 (20) 20 (25) In July 1966, audiometry was conducted and pure tone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 5 (15) 0 (10) 5 (15) 5 (10) LEFT 0 (15) 15 (25) 5 (15) 20 (30) 10 (15) The examination at service separation in August 1966 reveals essentially normal clinical findings for the ears (including auditory acuity). Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 (10) 0 (10) 5 (15) 5 (15) 5 (10) LEFT 0 (15) 5 (15) 5 (15) 15 (25) 15 (20) On a report of medical history at service separation, the Veteran reported that he had no history of hearing loss. The April 2005 VA examination report reflects that the Veteran had a bilateral hearing loss disability at that time. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 35 60 60 LEFT 15 35 60 60 60 The pure tone average for the right ear was 45 and the average for the left ear was 53.75. Speech recognition was 100 percent in the right ear and 96 percent in the left ear. The examiner's opinion was that the Veteran's bilateral hearing loss was less likely as not caused by or a result of military noise exposure based on the results from service. The RO denied service connection for bilateral hearing loss in June 2005. At the time of that decision, the only established fact was a current hearing loss disability. The unestablished facts at that time were (1) an injury or disease in service, (2) manifestation of hearing loss to a compensable degree within one year of service separation, continuity of symptomatology after service, and (2) a nexus between the current disability and service. Although notified of the RO's decision and of his right to appeal, the Veteran did not appeal that decision (see 38 C.F.R. § 20.200 (2013)); moreover, he did not submit any evidence within one year of that decision. Therefore, it became final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C.A. § 7105 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2013). In Buie v. Shinseki, 24 Vet. App. 242 (2010), the United States Court of Appeals for Veterans Claims (Veterans Court) vacated and remanded an earlier effective date claim (not at issue in this case) because the Board did not discuss the application of § 3.156(b) in its decision, but instead focused on the question of whether statements submitted within the appeal period following a rating decision satisfied 38 C.F.R. § 20.201 and were notices of disagreement. Buie, Vet. App. at 252. Essentially, the Veterans Court indicated that, because the statements were submitted within one year of the corresponding RO decision, the Board should have considered whether the statements included the submission of new and material evidence. In this case, nothing was received within the appeal period. Notwithstanding the finality of the June 2005 decision, VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). In Shade v. Shinseki, 24 Vet. App. 100 (2010), the Veterans Court held that 3.159(c)(4) does not require new and material evidence as to each previously unproven element of a claim for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern where a prior denial was based on lack of current disability and nexus, the Veterans Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. The Veteran applied to have the previously denied claim reopened in June 2008. Regarding applications for reopening filed on or after August 29, 2001, 38 C.F.R. § 3.156(a) defines "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim(s) sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Board must review all evidence submitted by or on behalf of a claimant since the last disallowance on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996), overruled on another basis by Hodge v. West 155 F.3d. 1356 (Fed. Cir. 1998). Furthermore, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The evidence received since the June 2005 decision includes the Veteran's written assertion in the March 2010 VA Form 9 that his hearing began to lessen about 1 year prior to service separation. Presuming the credibility of this assertion for purposes of the application to reopen, the Board finds that this assertion addresses the unestablished facts of whether there was an injury or disease in service and manifestation of a hearing loss disability within 1 year of service separation. There was no such evidence at the time of the June 2005 rating decision. Presuming the credibility of the assertion, it raises a reasonable possibility of substantiating the claim. Accordingly, the Board finds that the criteria for reopening the claim of entitlement to service connection for bilateral hearing loss are met. Merits of Hearing Loss Claim The Veteran contends that his current hearing loss disability is related to noise exposure in service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veterans Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Certain specific conditions are considered chronic diseases under VA law. These include organic diseases of the nervous system. Where an organic disease of the nervous system is shown to be chronic in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war or after December 31, 1946, and any of the chronic diseases becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran's current hearing loss disability is not related to service. The Veteran has a current bilateral hearing loss disability for VA purposes. When examined in July 2011, the following pure tone thresholds were recorded: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 30 55 60 LEFT 15 40 60 55 65 The pure tone average in the right ear was 37.5; the average in the left ear was 55. Speech recognition was 94 percent in the right ear and 94 percent in the left ear. Regarding the Veteran's assertion in the VA Form 9 that his hearing began to lessen 1 year prior to service separation, this is contradicted by the clinical evidence. The Veteran's hearing was regularly tested during service and was always clinically normal. The Veteran asserted in his January 2005 claim that his hearing loss began in 1964 and that he was treated for hearing loss from 1964 to 2005. The Board finds that this assertion is also inaccurate. The Veteran was never treated in service for complaints of hearing loss, and the essentially normal audiograms taken during service are probative and convincing evidence against the onset of hearing loss during service. Indeed, the first reference to hearing loss, for VA purposes, in the record comes in the context of the January 2005 claim received almost 40 years after service separation. Also of great significance in the Board's determination that the Veteran's current assertions as to onset of hearing loss during service are not accurate is the report of medical history at service separation. On this report, the Veteran recorded his comprehensive medical history, and he specifically indicated that he had no history of hearing loss. Apart from the clinical findings, this is significant evidence that the Veteran did not perceive any impairment in his hearing at any time in his history, but specifically during service. The Board attaches great probative weight to this report as it is bolstered by regular audiograms demonstrating consistently normal hearing. In weighing this report against the recent conflicting statements, the point in time in which the statements were made is important because a recounting of an event which is closer to the time that event occurred is naturally less likely to be diluted by the shortcomings of memory. Thus, the contemporaneous nature of the statement of medical history at discharge is significant. Furthermore, because the Veteran was then seeking only medical evaluation, it seems likely that he would report events carefully and accurately. Statements made to physicians for purposes of diagnosis and treatment are deemed exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. In contrast, the recent accounts are made in the context of claims for VA benefits. The Board is of course cognizant of possible self interest which any veteran has in promoting a claim for monetary benefits. The Board may properly consider the personal interest a claimant has in his or her own case, but the Board is not free to ignore his assertion as to any matter upon which he is competent to offer an opinion. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). There is no question that the Veteran is competent to relate events as he remembers them. Thus, his competency is not at issue with regard to recounting the events of service. Rather, it is the accuracy of the Veteran's recent accounts which the Board finds to be lacking. Simply put, the Veteran's denial of any history of hearing loss on the report of medical history at separation from service is more convincing than the Veteran's recent statements, which were made in support of a claim for monetary benefits. The assertions made by the Veteran in the January 2005 claim and March 2010 VA Form 9 as to onset of symptoms of hearing loss in service are not credible. Regarding continuity of symptomatology after service and manifestation of sensorineural hearing loss to a compensable degree within a year of service separation, the Board finds that the evidence weighs against these elements. In fact, the criteria for a compensable rating for hearing loss have not been demonstrated at any time since service, including in the most recent July 2011 evaluation. See 38 C.F.R. § 4.85, Diagnostic Code 6100 (2013). The Veteran's assertions regarding continuity of symptomatology are inextricably linked to his assertion as to in-service onset of symptoms. The Board has found that these assertions are not credible. Turning to the etiology of the Veteran's hearing loss disability, after reviewing the Veteran's history as documented in the claims file, the July 2011 VA examiner opined that the Veteran's current bilateral sensorineural hearing loss is less likely as not caused by or the result of the Veteran's history of military noise exposure. The rationale for this opinion was that the separation examination documented hearing that was within normal limits at .5 to 6 kilohertz. There is no medical opinion of record that purports to relate the Veteran's hearing loss to service. The Board acknowledges that the Veteran did experience noise exposure in service and that he is service-connected for tinnitus as a result. However, the Board finds the opinions of the July 2011 and April 2005 VA examiners to be persuasive on the question of etiology of hearing loss, because each includes a rationale that is consistent with the record. In contrast, the Veteran's recent assertions conflict with the record. The Veteran's service treatment records reflect that, at service separation, the Veteran's hearing at each frequency examined was normal, as it had been at service entrance, and that he denied any history of hearing loss. The Board acknowledges the holding of the Veterans Court in Hensley, 5 Vet. App. at 159 that VA law does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service, and that when audiometric test results at separation from service do not meet regulatory requirements for establishing disability, a veteran may establish service connection for current hearing disability by submitting evidence that current disability is causally related to service. While the above is true, the Board distinguishes the facts in this case from those in Hensley. In Hensley, the claimant's right-ear hearing acuity had worsened during service; however, the Board in that case limited its discussion to findings that a right-ear hearing disability was not manifested during service or to a degree of 10 percent during the one-year presumption period following service. The Veterans Court affirmed the Board's findings as to in-service manifestation of a right-ear hearing loss disability and manifestation within the presumptive period. The Veterans Court limited its remand to a determination as to whether the claimant's right-ear hearing disability was causally related to in-service noise exposure. Notably, in Hensley, the record contained private medical reports stating that the claimant's hearing loss was probably due to noise trauma, including exposure to jet-aircraft noise during service. Here there are two medical opinions addressing the claimed relationship to noise exposure in service, and there is no contradictory medical opinion evidence of record. The deficiencies found by the Veterans Court in Hensley are not present in this case. The Veteran has asserted that his hearing loss disability is related to service. Lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). In some cases, establishing the etiology of hearing loss may be capable of lay observation, such as when the onset of hearing loss is in close temporal proximity to an injury or disease. In this case, the Board has found the Veteran's assertions as to in-service onset of hearing loss to be lacking in credibility and to be untrue. The Board has also found that there is no continuity of symptomatology after service. The Board here finds that establishing the etiology of hearing loss that is temporally remote from the asserted acoustic injury 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). The Veteran's opinion as to the etiology of his hearing loss is not competent evidence. As the criteria for service connection for bilateral hearing loss are not met, the Board concludes that service connection for bilateral hearing loss is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Hypoglycemia Claim The Veteran asserts that he has a current disability manifested by hypoglycemia. He asserts that the doctor who performed a 1971 subtotal gastrectomy told him that hypoglycemia was directly related to that operation, and that the first episode of hypoglycemia occurred 3 months after the procedure. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that there is no current chronic disability manifested by hypoglycemia. The Board finds that hypoglycemia is not itself a disability, but is a clinical finding. However, the Board acknowledges that hypoglycemia may in some cases be a manifestation of disability where it causes impairment of function. The Veteran has not been clear as to what if any functional impairment he believes is attributable to the claimed hypoglycemia. In an April 2010 examination, he reported that, subsequent to the 1971 gastrectomy he became weak and was found to have a vitamin deficiency; it was claimed to be due to hypoglycemia or rheumatoid arthritis and the treatment for rheumatoid arthritis. Nevertheless, to the extent that there has been functional impairment due to hypoglycemia historically, the Board finds that there is no current disability manifested by hypoglycemia. The Board notes that the April 2010 VA examiner, although attempting to determine the residual disabilities stemming from the gastrectomy, did not include a diagnosis of hypoglycemia. The clinical records in this case do occasionally reference the assertion of the Veteran that he has a history of low sugar reaction or hypoglycemia. A VA examiner in September 2009 reported that the Veteran's past GI history includes "low sugar reaction." An April 2010 examination includes a reference to hypoglycemias subsequent to the 1971 gastrectomy. Records from the Kent County Memorial Hospital Outpatient Infusion Unit dated in 2006 and 20007 note a history of hypoglycemia. A June 2001 examination report from the Kent County Memorial Hospital notes that the Veteran reported that "he also has had problems with hypoglycemia." However, nowhere in the claims file is there a notation of hypoglycemia contemporaneous to this claim or a description of any resulting functional impairment. Most significant, a serum glucose reading in January 2006 was 90mg/dl. The report notes that the normal range is between 65mg/dl and 99mg/dl, thus establishing that the Veteran's glucose was normal. The record also contains numerous serum glucose findings from 1985 to 2000, which although prior to the current claim, are pertinent to determining whether there is a chronic disability. In August 1985, March 1988, June 1988, September 1988, November 1988, December 1988, March 1989, August 1989, September 1989, January 1991, May 2000, June 2000, and August 2000, the Veteran's glucose readings were within the normal range provided. In January 1990, the glucose reading was above the normal range provided. The only reading that is below the normal range comes in April 1988 with a reading of 65mg/dl compared to the normal range provided on that report of 70mg/dl to 115mg/dl. The Board emphasizes that it acknowledges that there has been a history of hypoglycemia. However, this single low reading comes decades prior to the period on appeal. The evidence pertinent to the period of this claim is entirely negative regarding current hypoglycemia. The Board recognizes that the Veterans Court has held that the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, in this case, there is no clinical evidence of current hypoglycemia or diagnosis of hypoglycemia at any time during the period of the current claim. Historical references to hypoglycemia, where, as here, they extend decades prior to the current claim, are not probative of the existence of a current disability. Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in a current disability. See 38 U.S.C.A. § 1110. Hence, where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no current chronic disability manifested by hypoglycemia, the Board concludes that service connection for the claimed hypoglycemia is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Veterans Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the Veteran submitted his claims in June 2008. He was sent a letter in July 2008 which advised him of the information and evidence necessary to substantiate his claims. That letter also advised him as to how disability ratings and effective dates were assigned in the event of a successful claim seeking service connection. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Since the July 2008 letter was sent to the Veteran prior to the initial adjudication of the claims in October 2008, there exists no error in the timing of this notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In short, VA has complied with its duty to notify the Veteran in this case. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's written assertions regarding the claims. In addition, the Veteran was afforded a VA audio examinations to address the severity and etiology of his hearing loss. The examination was adequate because it was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The resulting opinion was accompanied by a rationale that is consistent with the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Board has considered whether it is necessary to submit the service entrance examination audiogram results to a medical professional to have the numeric values interpreted. The Board finds that this is not necessary. The VA examiner's who provided opinions on this issue had access to these results in formulating their opinions. While numeric interpretations were not provided, the results were interpreted as indicative of normal hearing acuity. The Board finds that a remand to obtain a numeric interpretation of the test results could not reasonably be expected to aid the Board in deciding the claim or to avail the Veteran, but would simply result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran; Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). While a VA examination was conducted to determine the current residuals of the Veteran's 1971 gastrectomy, and although the examiner noted the Veteran's report of a history of hypoglycemia, an opinion was not specifically requested or provided regarding whether there is a current chronic disability manifested by hypoglycemia. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Veterans Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, the evidence does not establish a current chronic disability manifested by hypoglycemia. The evidence regarding hypoglycemia appears to be historical in nature, predating the period on appeal. In essence, the evidence on this issue consists of conclusory generalized lay statements which are unsupported by even speculative medical evidence regarding the existence of a current disability. Accordingly, the Board finds that referral for a VA medical examination is not warranted. ORDER New and material evidence has been received and therefore the claim for service connection for bilateral hearing loss is reopened. Service connection for bilateral hearing loss is denied. Service connection for a chronic disability manifested by hypoglycemia is denied. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs