Citation Nr: 1335146 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-33 996A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from July 1960 to July 1963. This matter is on appeal from a May 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified before the undersigned Veterans Law Judge in April 2011. A transcript of the hearing is of record. The Board notes at the outset that the issue of entitlement to service connection for tinnitus was also appealed by the Veteran. However, in a January 2010 decision, the RO granted service connection for this disorder. This constitutes a full grant of that particular issue and, accordingly, it is no longer on appeal. This case was previously before the Board in September 2011, at which time the pending claims were remanded for further development. There has been substantial compliance with the actions requested in that Remand relating to the claim for a psychiatric disorder and that claim is ready for appellate consideration. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). As will be explained herein, further development of the service connection claim for bilateral hearing loss is required. For purposes of clarification, the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Therefore, the Board has generally characterized the issue as set forth on the title page, to allow for consideration of any diagnosed psychiatric disorder pertinent in this case. The Board further notes that at this point, service connection for posttraumatic stress disorder (PTSD) has not been claimed, nor does the record shown that any PTSD diagnosis been made. Hence, for purposes of this decision, PTSD need not be addressed. An October 2013 review of the Virtual VA (VVA) paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The service connection claim for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT There is no competent and probative evidence which relates the Veteran's psychiatric disorder to service. CONCLUSION OF LAW Service connection for a psychiatric disorder, is not warranted. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). The RO informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claims in a letter dated in March 2007, wherein the Veteran was advised of the provisions relating to the VCAA. The Veteran was advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to the VA. On March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA 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. 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. The Veteran was provided with notice of the type of evidence necessary to establish a disability rating or effective date as was discussed in the Dingess case in March 2007, prior to the adjudication of the claims in May 2007. The RO re-adjudicated the claims in a Statement of the Case (SOC) issued in September 2008 and in Supplemental SOCs issued in January 2010 and November 2012. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). The Veteran was also provided an opportunity to set forth his contentions during the April 2011 Board hearing. In Bryant v. Shinseki, the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the "hearing officer" who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 23 Vet. App. 488 (2010). The Board notes that the issue was addressed at the 2011 hearing and the development (relevant treatment records, medical examinations and nexus opinion) necessary to substantiate the claims was ordered by the Board in a September 2011 Remand. Thus, if error found, the Veteran was not prejudiced. See Bryant, 23 Vet. App. at 498-99 ("[A]lthough the Board hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the record reflects that they were developed by the Secretary-to include medical examination reports on each of these disabilities and any nexus to service-and there was no indication that the represented appellant had any additional information to submit. Accordingly, the 'clarity and completeness of the hearing record' was intact with respect to these disabilities and the purpose of § 3.103(c)(2) was fulfilled."). The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the service connection claim for a psychiatric disorder on appeal has been obtained. The Veteran's service treatment records (STRs) and post-service records including available private medical reports, and VA records dated to August 2011, have been obtained and associated with the file. Pursuant to a 2011 Board remand, the Veteran's historical treatment records were requested. Private medical records of Dr. R. I. dated from 1977 to 2008 are on file. In September 2011, the Veteran provided information to the effect that both Dr. S., and Dr. B., were retired/deceased and that no records were available from these sources. Attempts to obtain records of Dr. B.B. and Dr. T. were unsuccessful, as remote records from these sources were no longer available. VA's duty to assist also includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). During the appeal period, a VA psychiatric examination was conducted in October 2011, following which an addendum opinion was provided in August 2012. In light of the conflicting and confusing content of that opinion, a clarifying medical opinion of November 2012 was provided for the file. While the Veteran's representative appears to be unhappy with the most recent VA opinion and believes it was unnecessary, pursuant to the aforementioned explanation and further discussion herein, the August 2012 opinion was inadequate, and further development was necessary. The Veteran and his representative have not specifically maintained that the November 2012 VA opinion provided for the record is in any way inadequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate Accordingly, the Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). Background In February 2007, the Veteran filed a service connection claim for a psychiatric disorder, specifically claimed as depression. The Veteran indicated that the disorder began in 1961, and had been treated since 1990 by Dr. R.I. The DD 214 reflects service with the United States Army with an MOS of light vehicle driver/general repairman. The Veteran's STRs include a July 1960 enlistment examination report reflecting that a psychiatric evaluation was normal and that the Veteran denied having depression, excessive worry, frequent trouble sleeping, or nervous trouble of any sort. A May 1963 separation examination report also reflects that psychiatric evaluation was normal and that the Veteran denied having depression, excessive worry, frequent trouble sleeping, or nervous trouble of any sort. The STRs are entirely negative for any complaints, findings or diagnosis of a psychiatric nature. Records of Dr. R. I. dated from 1977 to 2008 are on file and are entirely negative for any treatment or diagnosis of a psychiatric nature; the records do document numerous joint problems impacting the ankle, right shoulder, back, hip, neck, arm, and other areas, and document diagnoses of gout, bursitis, and arthritis. Records of 1993 document left hip pain and the Veteran's reports of being under a great deal of stress. A March 1997 note indicated that the Veteran could not work as a result of multiple joint pain. It was noted that he was under a great deal of stress. A June 1999 record indicates that medications including Klonopin were apparently refilled in conjunction with the Veteran's symptoms of gout, causing pain. Klonopin was also refilled as shown in June 2001 and November 2007. VA records indicated that the Veteran's initial treatment began in August 2001, at which time he did not give a history of psychiatric treatment and had no complaints of a psychiatric nature. In November 2002 and August 2004, the Veteran underwent depression screens which were negative and findings were made that the criteria for depression were not met. A PTSD screen conducted in January 2007 was also negative. A VA mental health record dated in March 2009 reflects that the Veteran was told by his doctor that Klonopin was not an anti-depressant, contrary to him thinking that this medication had been described for depression. The Veteran gave a history of being in a sheltered home, and found that joining the military was a shock because of the rough language and yelling. He indicated that this made him nervous and led to sleeping problems. Dysthymia was diagnosed at that time. The Veteran presented testimony at a travel Board hearing held in April 2011. At that time, he indicated that he had been receiving treatment for depression/psychiatric symptoms for about 18 to 20 years, largely due to his behavior around family members. He indicated that he was having symptoms of irritability and family problems and that Klonopin had been prescribed for anxiety. The Veteran stated that he believed that his psychiatric disorder began in service, after being exposed to cussing and being made to follow orders (p. 16). VA records reflect that the Veteran was seen in August 2010 at which time he was recovering from his wife's death. Symptoms of anxiety, depression and insomnia were recorded. Dysthymia was diagnosed. A VA examination for mental disorders was conducted in October 2011 and the claims file was reviewed. Depressive disorder was diagnosed. On examination, the Veteran gave a 20 years history of being treated for anxiety. He did not report having psychiatric symptomatology since service. The examiner indicated that she was unable to etiologically related the Veteran's claimed psychiatric condition to his military service without resort to speculation, as there was not enough information in the records to make the opinion. She noted that the STRs were negative for indications of psychiatric treatment or diagnosis, and that the Veteran did not report having mental health treatment in service. She did mention that the Veteran gave a long-standing history of depressed mood, irritability, and sleep disruption. In an addendum provided in August 2012, the same examiner who conducted the October 2011 VA examination, mentioned that she was unable to locate any new information regarding the Veteran's history of depression/treatment and therefore her previous opinion remained intact to that extent. However, she noted that the Veteran had reported in the records a lay history of mental health symptoms since service and that based on his lay reports alone, it was considered to be as likely as not that diagnosed depressive disorder was related to the Veteran's military service. In November 2012, a VA clarifying opinion was added for the file to the effect that the Veteran's claimed mental health condition was less likely than not incurred in or caused by service. In support of the opinion, the physician emphasized that the Veteran had no evaluations for mental health related complaints or issues while on active duty and that even with a 20 year history of mental health treatment post-service, this would still place the onset of a mental health condition to approximately 30 years post-service. Analysis The Veteran maintains that service connection is warranted for a psychiatric disorder, claimed as depression. Generally, in order to prevail on the issue of service connection, there must be evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). 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." Continuity of symptomatology is required only where the condition noted during service 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) (2013). However, the U.S. Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) "restricts itself to chronic diseases" found in 38 C.F.R. § 3.309(a). See Walker v. Shinseki,708 F.3d 1331 (Fed. Cir. 2013) ("Nothing in § 3.303(b) suggests that the regulation would have any effect beyond affording an alternative route for proving service connection for chronic diseases."). As discussed below psychoses are listed as a type of chronic disease under the provisions of 38 C.F.R. § 3.309(a). Service connection shall be granted to a veteran if the veteran served 90 days or more during a war period or after December 31, 1946 or had peacetime service on or after January 1, 1947, and conditions including psychoses, although not otherwise established as incurred in or aggravated by service, are manifested to a compensable degree within one year following the requisite service. 38 C.F.R. §§ 3.307, 3.309 (2013). The Board notes that there is no evidence of the Veteran having a psychosis. Therefore, this provision is not applicable. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The Board acknowledges that post-service VA records include a psychiatric diagnosis of dysthymic disorder and upon VA examination of October 2011, depressive disorder was diagnosed. Accordingly, evidence of the currently claimed disorder has been established. The Board notes that PTSD has never been diagnosed in this case, in or since service. The Veteran's STRs are negative for reports or a diagnosis of a psychiatric disorder in service or upon separation evaluation of May 1963, and the Veteran denied a history of depression, excessive worry, frequent trouble sleeping, or nervous trouble of any sort upon separation examination. In this regard, the Board finds that the May 1963 report of medical examination, which was completed less than 2 months prior to the Veteran's separation from service, is highly probative as to the Veteran's condition at the time nearest his release from active duty, as it was generated with the specific purpose of ascertaining the Veteran's current history, as opposed to his current assertion which is proffered in an attempt to secure VA compensation benefits. Rucker v. Brown, 10 Vet. App. 67, 73 (1993) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of reasons for the Board's decision). As such, the Board finds that the Veteran's assertion of having psychiatric symptoms in service is not credible given his history contemporaneous to service. The Board also finds it significant that the Veteran reported that his initial symptoms began in 1961 and were manifested by nerves and trouble sleeping. However, according to the May 1963 separation examination report, psychiatric evaluation was normal and the Veteran specifically denied having depression, excessive worry, frequent trouble sleeping, or nervous trouble of any sort. His failure to report any such complaints on separation from service is persuasive evidence that he was not then experiencing any relevant problems and outweighs his present recollection to the contrary. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). As such, there is reason to question the credibility and reliability of any lay information provided by the Veteran to the effect that the onset of his psychiatric symptoms was during service. A veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his active service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). In this case, the file contains 3 medical opinions addressing the matter of an etiological association between the Veteran's claimed and diagnosed psychiatric disorder and his military service. The October 2011 a VA examiner indicated that she was unable to etiologically relate the Veteran's claimed psychiatric condition to his military service without resort to speculation, as there was not enough information in the records to make the opinion. The Board is cognizant of the holding of Jones v. Shinseki, 23 Vet. App. 382 (2010), where the Court stated that while VA need not "proceed through multiple iterations of repetitive medical examinations until it obtains a conclusive opinion or formally declares that further examinations would be futile," it must be clear "that the examiner has not invoked the phrase 'without resort to mere speculation' as a substitute for the full consideration of all pertinent and available medical facts to which a claimant is entitled." In essence, the Court in Jones acknowledged, there are instances where a definitive opinion cannot be provided because required information is missing or can no longer be obtained or current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. The Court in Jones held, however, that in order to rely upon a statement that an opinion cannot be provided without resort to mere speculation, it must be clear that the procurable and assembled data was fully considered and the basis for the opinion must be provided by the examiner or apparent upon a review of the record. With regard to the October 2011 VA opinion, as detailed above, the VA examiner reviewed the claims folder, summarized the relevant facts and history, and indicated that an opinion could not be provided as the etiology of the Veteran's psychiatric disorder, without resort to mere speculation largely due to the absence of historical information and historical evidence in the file. In this regard, the Board notes that the service records contained a history in which the Veteran denied frequent trouble sleeping, frequent or terrifying nightmares, depression or excessive worry, or nervous trouble. As such, the 2011 opinion of the VA examiner, while inconclusive is adequate. To be adequate, a medical opinion must do more than state a conclusion that etiology of a disability is unknown or unknowable; rather, the medical examiner must support his or her conclusion with sufficient rationale and explanation. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (holding that "the mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign the doctor's opinions"). That explanation was provided by the VA examiner in this case, especially in light of the fact that the Board finds that the Veteran did not have any psychiatric symptoms in service. However, the Board must observe as it relates to the 2011 VA medical opinion that as a practical matter, medical evidence that is speculative, general, or inconclusive in nature, such as the 2011 VA opinion, cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). In August 2012, an addendum VA opinion was provided by the same examiner providing the October 2011 opinion. This time, examiner mentioned that she was unable to locate any new information regarding the Veteran's history of depression/treatment and therefore her previous opinion remained intact to that extent. However, she noted that the Veteran had reported in the records a lay history of mental health symptoms since service and that based on his lay reports alone, it was considered to be as likely as not that diagnosed depressive disorder was related to the Veteran's military service. This opinion was based solely on lay evidence of the Veteran having psychiatric symptoms in service. The Board has rejected this finding based on the contemporaneous service records which show that the Veteran affirmatively denied having various psychiatric symptoms. An opinion based on an inaccurate factual premise lacks probative value and cannot be used to substantiate the nexus requirement in a service connection claim. In November 2012 another opinion was obtained. This opinion was clearly based on a comprehensive review of both the lay, clinical and historical evidence in this case. The VA physician concluded that the Veteran's claimed mental health condition was less likely than not incurred in or caused by service, explaining that the Veteran had no evaluations for mental health related complaints or issues while on active duty, and that even with a 20 year history of mental health treatment post-service, this would still place the onset of a mental health condition to approximately 30 years post-service. The examiner review the Veteran's service records, including the discharge report. The discharge report included the Veteran's denial of various psychiatric symptoms. In giving a negative opinion the examiner made it clear that he reviewed the Veteran's service records. The Board notes that these service records showed that the Veteran denied having various psychiatric symptoms. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board finds that the basis for the opinion was the service records and postservice records and that this gives the opinion significant probative value. The November 2012 VA opinion took into account and discussed the Veteran's lay and clinical history. Accordingly, the November 2012 VA opinion is found to be the most probative opinion on file, as it is definitive, based upon a complete review of the Veteran's entire claims file, and supported by detailed rationale. The Veteran has not provided any competent medical evidence to rebut the aforementioned VA opinion or to otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). The Board acknowledges the Veteran's lay assertions to the effect that his currently claimed psychiatric disorder is related to service. However, the Board finds that this opinion as to etiology of a medical condition is a determination that is medical in nature. The Veteran, as a layperson, does not have the medical training or expertise to render a competent opinion on this matter, particularly in light of his numerous currently co-existing medical conditions, complicating his overall disability picture. See Davidson v. Shinseki, 581 F.3d 1313, (Fed Cir. Sept. 14, 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Accordingly, his contentions regarding etiology of his claimed psychiatric disorder are of no probative value, as they are beyond his competency to make. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (1998). Where, as here, the record lacks evidence of a nexus, a veteran may be entitled to disability benefits if he establishes continuity of symptomatology between the present condition and in-service injury or disease. See 38 C.F.R. § 3.303(b) (2013) (permitting a finding of service connection when continuity of symtomatology is established in lieu of medical nexus); Secretary's Br. at 11 (explaining that evidence showing both in-and postservice complaints of chest pain "could support an award of service connection on a theory of continuity of symptomatology"). In this regard it is established that psychoses are considered to be chronic diseases under 38 C.F.R. § 3.309(a). See Walker v. Shinseki,708 F.3d 1331 (Fed. Cir. 2013) (explaining that the continuity of symptomatology language in § 3.303(b) "restricts itself to chronic diseases" found in § 3.309(a)). As the Veteran has not been found to have a psychosis application of 38 C.F.R. § 3.303(b) is not warranted. Essentially, as the weight of the evidence is against a conclusion that the Veteran's currently claimed psychiatric disorder was incurred in or is otherwise related to service, the preponderance of the evidence is against this service connection claim. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. ORDER Entitlement to service connection for a psychiatric disorder, is denied. REMAND Additional development is warranted with respect to the Veteran's service connection claim for bilateral hearing loss. A brief review of the evidence reveals that the Veteran served in the Army from July 1960 to July 1963. According to his DD-214, his specialty was a light vehicle driver. At his hearing before the Board in April 2011, he explained that his duties were primarily as a chauffeur and testified that in this capacity, he drove officials to various locations, some of which involved live gunfire exercises, loud machinery and exposure to helicopters (T. at 3-4). He maintains that his current hearing loss is related to this noise exposure in service and states that he had hearing loss right before he got out of service and that it progressively worsened after service. Post-service medical records dated in 1992 document complaints of left ear discomfort and note an old perforation. Otitis media was diagnosed in May 1992. A June 1999 operative record indicates that at that time, left middle ear exploration with tympanoplasty was performed. That medical report documents a history of 3 prior tympanoplasties done at other hospitals. In November 2009, a VA physician opined that the Veteran's military noise exposure had not had an effect on his hearing, explaining that the Veteran's hearing was normal at the time he left service. The Board found this opinion inadequate for adjudication purposes, noting that the examiner provided no reason as to why it was significant that the Veteran's hearing was normal on discharge as a basis for finding no connection between the Veteran's current hearing loss and service. It was also pointed out that the claims file did not contain records of all of the Veteran's post-service ear surgeries. In a Remand issued by the Board in September 2011, it was requested that attempts be made to associate prior records of treatment and operative reports related to the ears/hearing loss with the file. In the 2011 Remand, the Board also requested a VA examination to determine the etiology of the Veteran's bilateral hearing loss. The examiner was asked to state whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's current hearing loss is related to service, including any acoustic trauma alleged to have occurred in service from 1960 to 1963. In giving the opinion, the examiner was directed to consider the Veteran's complete medical history, including his past ear surgeries to correct hearing loss. The examiner was also asked to discuss the significance, if any, of the lack of hearing loss in service, in giving the etiology opinion. A VA hearing loss examination was conducted in October 2011 and the claims file was reviewed. Mixed hearing loss was diagnosed and the examiner opined that this condition was not at least as likely as not caused by or the result of military service, explaining that the separation examination of May 1963 suggested hearing within normal limits bilaterally. Upon review, it is clear that the audiologist issuing the October 2011 opinion did not consider and discuss matters specified in the September 2011 Board Remand, to include addressing the significance, if any, of a finding of lack of hearing loss in service; which was the primary basis for the opinion provided. Further, the Board observes that it does not appear that the May 1963 separation examination report reveals hearing within normal limits bilaterally, as stated by the examiner. It is noted that service department audiometric readings prior to October 31, 1967, must be converted from American Standards Association (ASA) units to International Standard Organization (ISO) units, and it is not clear that the examiner made such conversion in this case. The conversion of the May 1963 separation examination audiogram yields the following pure tone threshold values in the right ear: 30 dB (500 Hz), 25 dB (1000 Hz), 20 dB (2000 Hz), XX dB (3000 Hz), and 5 dB (4000 Hz); and in the left ear: 20 dB (500 Hz), 15 dB (1000 Hz), 5 dB (2000 Hz), XX dB (3000 Hz), and 20 dB (4000 Hz). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Accordingly, there appear to be indications of some degree of hearing impairment on separation. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, given the concerns identified above, the Board concludes that a remand is required to ensure compliance with the Board's October 2012 remand. See Stegall, 11 Vet. App. at 271. Hence, given the deficiencies discussed above, the RO should forward the claims file to the audiologist who conducted the October 2011 examination and provided opinions at that time, for an addendum opinion to provide a clearly-stated rationale addressing the matter of whether the Veteran's claimed hearing loss is at least as likely as not related to noise exposure in service, or otherwise etiologically related to service, as contended, specifically addressing evidence of record, including: the Veteran's lay statements relating to the onset and course of his hearing loss, his history of acoustic trauma; the STRs - particularly the 1963 separation examination findings as converted, and nature of the Veteran's MOS and primary service functions; the history of left ear problems and surgeries; and the November 2009 and October 2011 VA examination reports and opinions. The RO should only arrange for the Veteran to undergo VA examination by an ear nose and throat (ENT) physician (preferably) or audiologist if the October 2011 examiner is not available, or another examination of the Veteran is deemed warranted. Accordingly, these matters are hereby REMANDED for the following action: 1. Forward the entire claims file, to include a complete copy of this REMAND, to the same audiologist who provided the October 2011 opinion, in order to obtain an adequate opinion with complete rationale addressing whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the Veteran's bilateral hearing loss was caused by or is a result of military noise exposure, or is otherwise etiologically related to service. (a) In providing this rationale, the audiologist should specifically consider and discuss: the Veteran's lay statements relating to the onset and course of his hearing loss, his history of acoustic trauma; the STRs - particularly the 1963 separation examination findings as converted, and nature of the Veteran's MOS and primary service functions; the history of left ear problems and surgeries; and the November 2009 and October 2011 VA examination reports and opinions; as well all other pertinent post-service medical evidence such as VA records. In answering the question posed above, the examiner is advised that the Veteran is generally considered competent to provide lay reports relating to matters within his personal knowledge, such noise exposure, types and severity of symptoms, and historical medical treatment. Such lay reports should be considered, to the extent made, in formulating the requested opinions. If the Veteran's lay reports are discounted, the examiner should provide a rationale for doing so. A complete rationale should be given for any opinion expressed. (b) If the prior examiner is not available, or further examination of the Veteran is deemed warranted, the RO should arrange for the Veteran to undergo examination, by an appropriate Ear, Nose and Throat (ENT) physician, preferably, or audiologist at a VA medical facility, to obtain medical opinions addressing the questions posed above. In this event, the entire claims file, to include a complete copy of the REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All appropriate tests and studies should be accomplished (with all results made available to the examining physician prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should address the medical opinion request noted above concerning the etiology of any current hearing loss. 2. Readjudicate the Veteran's claim of entitlement to service connection for bilateral hearing loss. If any action taken is adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 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). ______________________________________________ K. OSBORNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs