Citation Nr: 1335368 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 11-21 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II, to include as due to exposure to herbicides. 2. Entitlement to service connection for bilateral eye disability. 3. Entitlement to service connection for disability manifested by poor circulation. 4. Entitlement to service connection for a chronic upper respiratory disability, to include sinusitis. 5. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety disorder. 6. Entitlement to service connection for a sleep disorder. ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran served on active duty from January 1971 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Winston-Salem, North Carolina. The Board observes that the Veteran submitted additional private medical evidence along with his August 2013 motion to advance his case on the docket that has not been considered by the RO. However, this medical evidence pertains to the Veteran's hepatitis C disability, which is not currently before the Board, and does not address any of the disabilities on appeal. As such, this evidence is not pertinent to the claims on appeal and thus, waiver of RO consideration of this evidence is not necessary. 38 C.F.R. § 20.1304 (2012). The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a disability claim includes any 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); Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). Therefore, in light of such decisions, the Board has recharacterized the issues on appeal to encompass all possible disorders. The Veteran's electronic (Virtual VA) paperless claims file includes additional VA treatment dated to March 2013, which were considered by the RO in the most recent supplemental statement of the case issued in March 2013. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for an acquired psychiatric disorder and a sleep disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran did not serve in the Republic of the Vietnam during his active service, and exposure to herbicides during his active duty service is not otherwise shown. 2. Diabetes mellitus, type II, was not manifested during the Veteran's active duty service or for many years thereafter, and is not otherwise related to his active duty service. 3. A bilateral eye disability was not manifested during the Veteran's active duty service, and is not otherwise related to his active duty service. 4. A disability manifested by poor circulation was not manifested during the Veteran's active duty service, and is not otherwise related to his active duty service. 5. A chronic upper respiratory disability, to include sinusitis, was not manifested during the Veteran's active duty service, and is not otherwise related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type II, have not been met. 38 U.S.C.A. §§ 1101, 1112, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for a bilateral eye disability have not been met. 38 U.S.C.A. §§ 1101, 1112, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 3. The criteria for service connection for a disability manifested by poor circulation have not been met. 38 U.S.C.A. §§ 1101, 1112, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 4. The criteria for service connection for a chronic upper respiratory disability, to include sinusitis, have not been met. 38 U.S.C.A. §§ 1101, 1112, 1110, 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 VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Here, the Veteran was sent a letter in May 2008, which was prior to the initial RO decision in this matter. The letter provided information as to what evidence was required to substantiate his service connection claims and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, the letter informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date in accordance with Dingess/Hartman, supra. Accordingly, VA has satisfied its duty to notify under the VCAA. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains service treatment and personnel records and post-service VA treatment records. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Moreover, the Board has carefully reviewed the Veteran's statements and concludes that no other available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. With respect to the issues on appeal decided herein, the Veteran has not been afforded a VA examination. 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); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the 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). In this case, the service treatment records are silent as to any complaints or treatment for diabetes mellitus, eye disability, poor circulation and/or a chronic upper respiratory disability. Moreover, the Veteran has asserted that his diabetes mellitus is due to exposure to herbicides. However, as discussed further below, the record clearly shows that the Veteran was never stationed in Vietnam or otherwise exposed to herbicides. Furthermore, the record contains no competent or credible evidence suggesting a causal relationship between any current disability and active service. The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). For all of these reasons, the evidence does not indicate that the claimed disabilities may be related to active service such as to require an examination, even under the low threshold of McLendon. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis 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; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) . When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Diabetes Mellitus, Type II The Veteran is seeking service connection for diabetes mellitus, type II. Specifically, the Veteran claims that his diabetes mellitus, type II, is due to exposure to herbicides. He has indicated that he was told that diabetes was service-related for Veterans who served during the Vietnam War era. He reported that he drove an ambulance while stationed at Fort Sill, Oklahoma, that put him in contact with other service members who had served in Vietnam and, in turn, exposing him to herbicides through contact with these soldiers. He further stated that he had no knowledge of having diabetes until he received treatment at the VA. For purposes of establishing service connection for a disability resulting from exposure to a 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, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f). Moreover, it is provided that the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.308(a)(6)(ii). These diseases include type II diabetes. 38 C.F.R. § 3.309(e); see Notice, 75 Fed. Reg. 168, 53202-16 (Aug. 31, 2010). In addition, the United States Court of Appeals for the Federal Circuit has determined that a Veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Secretary of VA has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See, e.g., Notice, 68 Fed. Reg. 27,630-41 (May 20, 2003). See also Notice, 68 Fed. Reg. 27, 630-41 (May 20, 2003), and Notices at 61 Fed. Reg. 57, 586-589 (1996); 64 Fed. Reg. 59, 232-243 (1999); and 67 Fed. Reg. 42, 600-608 (June 24, 2002). See also Veterans and Agent Orange: Update 2006 (2007). The Veteran's military personnel and service records do not document any service in Vietnam. Rather, his service personnel records showed that the Veteran was always stationed stateside. Moreover, the Veteran has never asserted that he served in Vietnam. Rather, he claims exposure by contact with other service members returning from Vietnam. In sum, there is no evidence that he served in Vietnam. Further, service treatment records are silent with respect to any treatment for or symptoms of diabetes mellitus, type II. Importantly, the Veteran's service examination prior to discharge in March 1974 was silent with respect to any diagnosis of diabetes mellitus, type II. In an April 1974 statement, the Veteran indicated that there had been no change in his medical condition since the previous examination. Post-service VA treatment records document that the Veteran was diagnosed with diabetes mellitus, type II, approximately in August or September 2003 at the VA clinic in Winston-Salem. Follow up VA treatment records continued to show a diagnosis of diabetes mellitus, type II, but do not provide an etiological opinion. Applying the pertinent legal criteria to the facts summarized above, the evidence of record shows that the Veteran had no actual duty in, or that he visited the Republic of Vietnam, at any time during his military service. Thus, the Board finds that the probative evidence of record fails to demonstrate service in the Republic of Vietnam and, as such, the Veteran may not be presumed to have been exposed to herbicides coincident with such service. Furthermore, the record does not otherwise show, that he was exposed to herbicides at any other point during his military service. The Board acknowledges that the Veteran asserts that he was exposed through contact with other members. However, there is simply no persuasive evidence and the Board is unaware of any official findings that one could be exposed to herbicides through contact with other service members who served in Vietnam without ever having been directly exposed to herbicides. Thus, although the Veteran has been diagnosed with diabetes mellitus, type II, a presumptive disability for herbicide exposure, the Board finds that the presumptive regulations regarding exposure to herbicides (Agent Orange) are not applicable in this case. See 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). The Board now turns to whether service connection for diabetes mellitus is warranted on a direct or presumptive basis. The Veteran's service treatment records do not show any treatment or diagnosis of diabetes mellitus. Further, the Veteran's March 1974 service examination prior to discharge was silent with respect to any findings of diabetes mellitus. VA treatment records showed that the Veteran was diagnosed with diabetes mellitus, type II, approximately in August 2003, many years after his discharge from service. Therefore, as the Veteran did not manifest diabetes mellitus within one year of his service discharge in May 1974, he is not entitled to presumptive service connection for such diseases. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Additionally, as will be discussed below, there is no evidence of continuity of diabetes symptomatology following the Veteran's service discharge. See Walker, supra. Moreover, there is no competent evidence linking diabetes mellitus directly to service. Here, the Veteran is not competent to directly link any current disability, to include diabetes mellitus, to service as medical expertise is required. In this regard, the question of causation in this case involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such concerns the inner workings of the endocrine system. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson, supra; Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Nevertheless, the Board observes that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Citing Buchanan and Jandreau, the Federal Circuit reiterated that it had previously and explicitly rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, in the instant case, there is simply no evidence, lay or medical, to support any findings of pertinent symptomatology. See Walker, supra. Although the Veteran indicated that he had no knowledge that he had diabetes until he was treated at VA, he has not provided any lay evidence describing any symptoms since service. Moreover, again, the medical evidence shows that he was not diagnosed with diabetes mellitus until 2003. In sum, the Board must conclude that with no evidence of diabetes mellitus, type II, in service or for many years after discharge from service, and no competent evidence of record suggesting a link between the Veteran's current disease and his active duty service, there is no basis for awarding service connection for diabetes mellitus either on a direct basis or under the one-year presumption. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the Veteran's claims for diabetes mellitus, type II. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). Bilateral Eye Disability The Veteran is also seeking service connection for a bilateral eye disability. He has asserted that he began experiencing vision problems in service that have worsened as time has passed. Service treatment records are silent with respect to any vision complaints or diagnosis of a bilateral eye disorder. During the March 1974 separation examination, his eyes were noted to be normal upon clinical evaluation and no eye deficits were reported or documented. Testing revealed 20/20 vision. The Veteran initially filed a claim for service connection for an eye disability in March 2008. Post-service medical evidence reveals that in January 2006, the Veteran presented at VA for a diabetic eye examination. The Veteran reported wearing reading glass for small print only and denied other eye symptoms. The assessment was diabetes without retinopathy, glaucoma suspect, early cataracts, myopia, and presbyopia. Follow up VA treatment records continued to show treatment for numerous eye disorders, including dry eye secondary to blepharitis, glaucoma suspect, cataracts, blurred/double vision, diabetes mellitus retinopathy, and pseudophakia. However, nothing in these records relate any current eye disability to the Veteran's service. Initially, in regard to the diagnoses of myopia, astigmatism, and presbyopia, the Board observes that service connection is not generally established for refractive error of the eye as it is not a disease or injury within the meaning of applicable legislation providing compensation benefits. 38 C.F.R. § 3.303(c), 4.9. Refractive error of the eyes includes myopia, presbyopia, and astigmatism. Id.; VA Manual M21-MR1, Part III, Subpart IV, Chapter 4, Section B, Para. 10(d). Further, absent superimposed disease or injury, service connection may not be allowed for a congenital or developmental defect of the eyes, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. Parker v. Derwinski, 1 Vet. App. 522 (1991); McNeely v. Principi, 3 Vet. App. 357, 364 (1992). Thus, in the absence of some event or trauma, a refractive error is a constitutional or development abnormality for which compensation benefits may not be authorized. 38 C.F.R. §§ 3.303(c), 4.9 (congenital or developmental defects, refractive error of the eye, personality disorders, and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation); see also VAOPGCPREC 82-90. In this regard, a congenital defect can be subject to superimposed disease or injury, and if superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. Id. In the instant case, there is no evidence that the Veteran's myopia, astigmatism, and presbyopia were subject to a superimposed disease or injury during his military service. Again, service treatment records are silent with respect to any such disease or injury and the Veteran has not asserted any such event. Moreover, after considering the totality of the evidence of record, the Board finds that service connection for any other bilateral eye disorder is also not warranted as there is no competent evidence linking any disability to service. Indeed, service treatment records are completely silent with respect to any eye problems. Importantly, the Veteran's eyes were clinically normal at the time of his discharge examination. Further, post-service VA treatment records showing an eye disability are dated many years after the Veteran's discharge from service and provide no evidence linking any current eye disability to service. Moreover, as the Veteran's bilateral eye disorders are not one of the diseases listed at 38 C.F.R. § 3.309(a), continuity of symptoms may not be used to establish service connection. See Walker, supra. Again, as noted above, the Board observes that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In the instant case, the Veteran is competent to report an in-service vision problems, as well as pertinent symptomatology since service. However, he is not competent to directly link any current disability to service as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such an inquiry involves the knowledge of the ocular system. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson, supra; Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Moreover, the Board finds the Veteran's current assertions of symptoms in-service as well pertinent symptoms since service to not be credible. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). In the instant case, the Board finds that such statements are not credible as they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest. Importantly, the first post-service medical evidence of any eye disorders is not until January 2006, 32 years after his discharge from service, when the Veteran presented for a diabetic eye examination. Importantly, at that time the Veteran did not report any previous history of eye problems, especially ongoing since service, except the need to wear glasses to read small print. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Further, the Board also finds it significant that the Veteran did not assert any relation between a current disorder and service until he filed his claim in March 2008. It would be reasonable to assume that if the Veteran had been experience ongoing eye problems prior to this time, he would have reported them sooner. Therefore, the Veteran's current statements, made in connection with his pending claim for VA benefits, that he has experienced continuous symptoms since service are inconsistent with the contemporaneous evidence and cannot be deemed credible. Moreover, in light of the denial for service connection for diabetes mellitus, type II, there is no basis of the award for diabetic retinopathy. In conclusion, based on the analysis above, the Board finds that the preponderance of evidence is against the Veteran's claim for service connection for bilateral eye disability. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). Disability Manifested by Poor Circulation The current appeal also includes the issue of service connection for a disability manifested by poor circulation. In his notice of disagreement, the Veteran appeared to indicate that this disorder was related to his diabetes mellitus, type II. However, in his subsequent substantive appeal, the Veteran reported experiencing muscle aches and tiredness in service when required to do physical activities. He also reported that he was recommended for surgery on his neck due to circulation and nerve damage that was affecting his legs. Service treatment records are silent with respect to any circulation problems. During the March 1974 separation examination, his extremities were noted to be normal upon clinical evaluation and no deficits were reported or documented. Again, the Veteran filed his current claim in March 2008. While VA treatment records do document cervical spine and low back disabilities with pain radiating to the left lower extremity, they do not provide a clear diagnosis of a disability manifested by poor circulation. Further, there is no medical evidence of record linking any such disability to service. Therefore, after considering the totality of the evidence of record, the Board finds that service connection for a disability manifested by poor circulation is also not warranted as there is no competent evidence linking any disability to service. Indeed, service treatment records are completely silent with respect to any clinical findings. Importantly, the Veteran's extremities were clinically normal at the time of his discharge examination. It is unclear whether the Veteran currently has any such disability, nevertheless, even assuming that he does have a current disorder for VA purposes, there is no competent medical evidence linking any such disorder to service. It was many years after service until the first complaints of any such disability. Moreover, as a disability manifested by poor circulation is not one of those diseases listed at 38 C.F.R. § 3.309(a), continuity of symptoms may not be used to establish service connection. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) . Again, as observed above, the Board observes that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In the instant case, the Veteran is competent to report any in-service problems, as well as pertinent symptomatology since service. However, he is not competent to directly link any current disability to service as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such an inquiry involves the knowledge of the circulatory system. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson, supra; Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Moreover, the Board finds the Veteran's current assertions of symptoms in service as well pertinent symptoms since service to not be credible. Again, in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). In the instant case, the Board finds that such statements are not credible as they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest. The Veteran asserts that he felt tired and muscles ached after doing physical activity in service. However, these appear to be normal symptoms following such activity as opposed to any sort of symptoms related to a chronic disability. Nevertheless, service treatment records are silent with respect to any such complaints. Importantly, post service medical evidence is silent with respect to any clear complaints of poor circulation. When seeking treatment, the Veteran has not provided any such history of experiencing problems since service. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Further, the Board also finds it significant that the Veteran did not assert any relation between a current disorder and service until he filed his claim in March 2008. It would be reasonable to assume that if the Veteran had been experience ongoing problems prior to this time since he would have reported them sooner. Therefore, the Veteran's current statements, made in connection with his pending claim for VA benefits, that he has experienced continuous symptoms since service are inconsistent with the contemporaneous evidence and deemed not credible. The Veteran also asserted that his disability was related to his diabetes mellitus. Nevertheless, in light of the denial for service connection for diabetes mellitus, type II, there is no basis of the award of this disability on a secondary basis pursuant to 38 C.F.R. § 3.310. In conclusion, based on the analysis above, the Board finds that the preponderance of evidence is against the Veteran's claim for service connection for a disability manifested by poor circulation. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). Chronic Upper Respiratory Disability, to include Sinusitis Lastly, the Veteran is also seeking service connection for a chronic upper respiratory disability, to include sinusitis. Essentially, he has only reported that he is treated for this condition at the VA medical center and has provided no further information or evidence. Service treatment records are silent with respect to any upper respiratory complaints or findings of any chronic upper respiratory disorders. During the March 1974 separation examination, his nose and sinuses were noted to be normal upon clinical evaluation. Again, the Veteran initially filed his claim for service connection in March 2008. Post-service VA treatment records beginning in 2003 showed a past medical history of allergic rhinitis and acute sinusitis with history of frequent upper respiratory infections. However, nothing in these records link a current chronic upper respiratory disability to service. After considering the totality of the evidence of record, the Board finds that service connection a chronic upper respiratory disability is not warranted as there is no competent evidence linking any such disability to service. Indeed, service treatment records are completely silent with respect to any such problems. Importantly, the Veteran's nose and sinuses were clinically normal at the time of his discharge examination. While VA treatment records document a past medical history of upper respiratory disease, they do not link any current disability to service. Moreover, as a chronic upper respiratory disability, to include sinusitis, is not one of the disease listed at 38 C.F.R. § 3.309(a), continuity of symptoms may not be used to establish service connection. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) . Again, as observed above, the Board observes that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In the instant case, the Veteran has not provided any lay evidence of symptoms in service or pertinent symptomatology since service. Again, the first post service medical evidence of any chronic upper respiratory disability is many years after service. Moreover, he is not competent to directly link any current disability to service as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson, supra; Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In conclusion, based on the analysis above, the Board finds that the preponderance of evidence is against the Veteran's claim for service connection for chronic upper respiratory disability, to include sinusitis. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). ORDER Service connection for diabetes mellitus, type II, is denied. Service connection for a bilateral eye disability is denied. Service connection for a disability manifested by poor circulation is denied. Service connection for a chronic upper respiratory disability, to include sinusitis, is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the remaining claims so that the Veteran is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Initially, with respect to the claim for service connection for an acquired psychiatric disorder, the Veteran was afforded a VA examination in February 2011. After reviewing the claims file and examining the Veteran, the examiner diagnosed anxiety disorder, not otherwise specified. Although the examiner observed that the Veteran endorsed one event that occurred in service, which would meet the PTSD stressor criteria, where another person pulled a gun during an argument, the examiner determined that the Veteran did not meet the criteria for a diagnosis of PTSD. The examiner also concluded that the Veteran's anxiety disorder was not related to his military service. However, in his subsequent July 2011 substantive appeal, the Veteran reported another stressor incident where he and his fellow service members tried to revive a soldier who had overdosed on Pam cooking spray. The soldier died and the Veteran had to be interviewed by the Criminal Investigative Unit. Thus, the Board finds that the AOJ should attempt to verify this stressor event. Thereafter, the claims file should be returned to the same examiner who conducted the February 2011 VA examination for an addendum opinion. If the same examiner is not available, the Veteran should be afforded a new VA examination. Further, with respect to the Veteran's claim for service connection for a sleep disorder, service treatment records document that the Veteran reported sleep difficulty in September 1971. Post-service VA treatment records shows that the Veteran has been diagnosed with a breathing-related sleep disorder. The Veteran has reported that he experienced sleep problems in service that have continued since his discharge. As such, given the documentation in service, the current diagnosis of a sleep disorder and the Veteran statements of pertinent symptomatology, the Board finds that a remand is necessary to afford the Veteran a VA examination with etiological opinion in order to adjudicate his claim. In this regard, VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Lastly, while on remand, the Veteran should be given an opportunity to identify all treatment records referable to his acquired psychiatric disorder and sleep disorder. Further, it appears that the Veteran receives continuing treatment for his disabilities at the VA. As noted above, the most recent VA treatment records associated with the Veteran's Virtual VA record date from March 2013. In light of the need to remand and as VA medical records are constructively of record and must be obtained, the RO should obtain VA treatment records from March 2013 to the present. See 38 C.F.R. § 3.159; Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The Veteran should be given an opportunity to identify any healthcare provider who treated him for his acquired psychiatric disorder and sleep disorder. After securing any necessary authorizations from him, obtain all identified treatment records, to include additional VA treatment records from March 2013 to the present. 2. Contact the Veteran and request that he provide a specific time period for when the incident of the overdose by another soldier occurred and any additional information concerning the incident. Thereafter, contact any appropriate records repository, to include the U.S. Army and Joint Services Records Research Center or National Personnel Records Center, to attempt to verify this stressor incident. 3. After obtaining any outstanding records, send the claims file to the same VA examiner who conducted the February 2011 VA psychiatric examination and ask him to review the additional evidence, including the Veteran's assertions of the additional stressor incident, and request that he determine whether this evidence in any way changes his prior opinion. If the same examiner is not available, the Veteran should be afforded another VA psychiatric examination with a psychologist or psychiatrist. The claims file must be made available to the examiner for review. The examiner should identify all of the Veteran's acquired psychiatric disorders that meet the American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) criteria. The examiner should specifically indicate whether the Veteran meets the diagnostic criteria for PTSD and whether it is causally related to stressor incidents in service. Further, for each currently diagnosed acquired psychiatric disorder other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) that any such disorder is related to the Veteran's military service. In offering any opinion, the examiner must consider the full record, to include service treatment records, VA treatment records and the Veteran's lay statements. The examiner should provide a detailed rationale for every opinion provided. 4. After obtaining any outstanding records, the Veteran should be scheduled for an appropriate VA examination in order to determine the nature and etiology of his claimed sleep disorder. All indicated tests and studies should be undertaken. The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history. The examiner must identify all sleep disorders found to be present. With respect to each disorder diagnosed, the examiner should offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) related to the Veteran's military service, to include his reports of sleep difficulty in September 1971. In offering any opinion, the examiner must consider the full record, to include service treatment records, VA treatment records and the Veteran's lay statements. The examiner should provide a detailed rationale for every opinion provided. 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any of the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs