Citation Nr: 1336404 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 10-08 645 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial evaluation (rating) for bilateral hearing loss in excess of zero percent. 2. Entitlement to service connection for skin cancer, claimed as due to sun exposure. REPRESENTATION Appellant represented by: Robert W. Gillikin, Esq. ATTORNEY FOR THE BOARD B. J. Dempsey, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from September 1968 to September 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied service connection for bilateral hearing loss and skin cancer. In October 2012, the RO in Roanoke, Virginia issued a subsequent rating decision which granted service connection for hearing loss and assigned a noncompensable (zero percent) initial rating. In April 2013, the Board remanded the issue of service connection for skin cancer for further evidentiary development. After completion of the ordered development, the RO denied the claim, finding that the Veteran's skin cancer was not related to service. As part of the February 2010 VA Form 9 relating to both claims, the Veteran requested a hearing before the Board. In a May 2012 written statement signed by his representative, the Veteran withdrew his request for a hearing. Therefore, the request for a hearing has been withdrawn. With regard to the issue of service connection for skin cancer, the additional development actions have been completed and the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed the Veteran's physical claims files, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. FINDINGS OF FACT 1. For the rating period on appeal, the Veteran's service-connected hearing loss has measured as high as Level I in the right ear and as high as Level III in the left ear and there has been no exceptional pattern of hearing impairment that meets the criteria of 38 C.F.R. § 4.86. 2. The Veteran has been diagnosed with skin cancer, to include basal cell carcinoma and squamous cell carcinoma. 3. The Veteran was exposed to herbicides and sun while serving in the Republic of Vietnam. 4. Symptoms of the Veteran's skin cancer were not chronic in service, continuous since service, and did not manifest until several years after service. 5. The Veteran's skin cancer is not related to service. CONCLUSIONS OF LAW 1. The criteria for a compensable initial disability rating for bilateral hearing loss have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.383, 4.1 - 4.7, 4.10, 4.85, 4.86, DC 6100 (2013). 2. The criteria for service connection for skin cancer, claimed as due to sun exposure, have not been met. 38 U.S.C.A. §§ 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303. 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Procedural Duties under the Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and the representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When an initial rating appeal comes before the Board following a decision to grant service connection and assign an initial rating, no additional VCAA notice is required. Courts have held that, once service connection is granted and the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). As such, VA has satisfied its duty to notify with respect to the Veteran's initial rating appeal on the issue of hearing loss. Regarding the Veteran's claim for service connection for skin cancer, VA satisfied its duty to notify with a February 2009 notice letter. In that letter, the RO apprised the Veteran of the information and evidence necessary to substantiate the claim, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied prior to the initial denial of the claim in November 2009, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. With respect to the duty to assist, 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 that could be located, post-service VA treatment records, private medical records identified and/or submitted by the Veteran, and the Veteran's statements. Following the Board's April 2013 remand, the Veteran was also afforded a VA skin examination in August 2013 in relation to the claim for service connection for skin cancer. 38 C.F.R. § 3.159(c)(4) (2013). The VA examiner provided an in-person examination, reviewed the Veteran's claims file and medical history, and offered rationale for the conclusions reached. Accordingly, the Board finds that the August 2013 VA examination is adequate and no further medical examination or medical opinion is needed. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). This claim was subsequently readjudicated in an August 2013 supplemental statement of the case; therefore, the Board finds that there has been substantial compliance with the April 2013Board Remand order. See Stegall; D'Aries v. Peake, 22 Vet. App. 97 (2008). Similarly, the Veteran was provided with a VA audiological examination in August 2013. The VA examiner conducted all pertinent audiological tests, interviewed the Veteran, considered pertinent evidence of record, including the Veteran's medical history and personal statements, and presented the medical information necessary to apply the appropriate rating criteria. Thus, the Board finds that VA's duty to assist with respect to obtaining a VA examination concerning the issue adjudicated herein has been met. See 38 U.S.C.A. § 3.159(c). The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. Mayfield. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of these claims. II. Merits of the Claims A. Rating Legal Criteria and Analysis for Bilateral Hearing Loss Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7. The Court has indicated that a distinction must be made between a veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Here, the Board will evaluate the issue as a claim for higher evaluation of the original award. In such cases, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Id. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings - different disability ratings during various time periods - may be appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. For hearing loss claims, the Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. The "puretone threshold average," as used in Table VI, is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz), divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIA. 38 C.F.R. § 4.85(d). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hz are 55 decibels or greater, or when the puretone threshold at 1000 Hertz is 30 decibels or less and the threshold at 2000 Hz is 70 decibels or more. 38 C.F.R. § 4.86(a), (b). In October 2012, the RO granted a noncompensable initial evaluation for bilateral hearing loss, effective February 2009. The Veteran contends that his current level of bilateral hearing loss warrants a higher rating. After a review of all the evidence, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a higher (compensable) initial disability rating for any period. The evidence includes a June 2009 audiological examination performed by Dr. T.G., a private audiologist. The examination report reflects puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz in the right ear of 20, 20, 15, 55, and 45 decibels, respectively, with an average puretone threshold of 33.75 decibels (between 1000 and 4000 Hz). The same measurements yielded puretone thresholds in the left ear of 20, 20, 40, 65, and 55 decibels, respectively, with an average puretone threshold of 45 decibels (between 1000 and 4000 Hz). The examiner recorded speech recognition scores of 92 percent in the right ear and 88 percent in the left ear. The report does not specify whether the word recognition percentages were in accordance with the Maryland CNC test. For the purposes of this decision, the Board will assume that they are. The evidence also includes a June 2011 VA audiological examination, which reflects puretone thresholds at the frequencies of 500, 1000, 2000, 3000, and 4000 Hz in the right ear of 15, 15, 25, 55, and 55 decibels, respectively, with an average puretone threshold of 38 decibels (between 1000 and 4000 Hz). The same measurements yielded puretone thresholds in the left ear of 15, 15, 45, 65, and 55 decibels, respectively, with an average puretone threshold of 45 decibels. The examiner recorded speech recognition scores of 100 percent in the right ear and 96 percent in the left ear. Finally, an August 2013 VA audiological examination shows puretone thresholds at the frequencies of 500, 1000, 2000, 3000, and 4000 Hz in the right ear of 35, 35, 50, 65, and 70 decibels, respectively, with an average puretone threshold of 55 Hz (between 1000 and 4000 Hz). The same measurements yielded puretone thresholds in the left ear of 35, 40, 55, 70, and 65 decibels, with an average of 58 decibels (between 1000 and 4000 Hz). The examiner recorded speech recognition scores of 100 percent in the right ear and 88 percent in the left ear. Using Table VI and applying the results from the June 2009 private audiological examination, the hearing impairment is Level I in the right ear and Level II in the left ear. Applying those results to 38 C.F.R. § 4.85, Table VII, a zero percent evaluation is derived. As a result, the June 2009 examination by Dr. T.G. does not serve as a basis for a compensable rating. Using Table VI and applying the results from the June 2011 VA audiological examination, the hearing impairment is Level I in the right ear and Level I in the left ear. Applying those results to 38 C.F.R. § 4.85, Table VII, a zero percent evaluation is derived. Consequently, the June 2011 audiometric results do not serve as a basis for a compensable rating. Finally, using Table VI and applying the results from the August 2013 VA audiological examination, the hearing impairment is Level I in the right ear and Level III in the left ear. Applying those results to 38 C.F.R. § 4.85, Table VII, a zero percent evaluation is derived. Accordingly, the August 2013 audiometric results do not serve as a basis for a compensable rating. Additionally, these audiometric results do not demonstrate an "exceptional pattern of hearing" that meets the criteria of 38 C.F.R. § 4.86. First, the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz were not 55 decibels or greater across each frequency in either ear during the June 2009, June 2011, or August 2013 tests. See 38 C.F.R. § 4.86(a). Second, the puretone thresholds at 2000 Hertz were never more than 70 decibels during any test, making the variance-based impairment inapplicable. See 38 C.F.R. § 4.86(b). The level of hearing loss impairment has been relatively stable throughout the appeals period, or at least has never been worse than what is warranted for the rating assigned. Therefore, any application of staged ratings (i.e., different percentage ratings for different periods of time) is inapplicable. See Hart, 21 Vet. App. 505. Thus, in consideration of the above, the claim for an initial rating in excess of zero percent disabling must be denied. The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Extraschedular Consideration In analyzing the Veteran's appeal, the Board has considered whether referral for an extraschedular rating is warranted for the service-connected bilateral hearing loss. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court noted that, unlike the rating schedule for hearing loss, the extraschedular provisions did not rely exclusively on objective test results to determine whether referral for an extraschedular rating was warranted. The Court held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. To that end, the August 2013 VA audiological examination report states how the Veteran reported "hard hearing" as the impact of his condition on daily life. In the June 2011 VA audiological report, the Veteran is quoted as saying that he has trouble understanding speech clearly at times, especially in background noise. As these functional limitations are contemplated by the rating criteria, specifically the ability to hear and identify nearby sounds, the fact that the Veteran has a difficult time hearing does not trigger the need for an extraschedular evaluation. In this case, the schedular criteria are adequate to rate the Veteran's bilateral hearing loss disability. The schedular rating criteria specifically provide for ratings based on all levels of hearing loss, including exceptional hearing patterns which are not demonstrated in this case, and as measured by both audiological testing and speech recognition testing. The Veteran's complaints concern general hearing ability. Diminished auditory acuity and speech recognition testing are the foundation of the schedular criteria. Moreover, the testing is to be performed without the use of hearing aids. See 38 C.F.R. § 4.85(a). The scores represent a rating made on the worst possible objective measure of performance. In other words, he does not have any symptoms from his service-connected disability that are unusual or are different from those contemplated by the schedular criteria. The Veteran merely disagrees with the assigned evaluation for his level of impairment. For these reasons, the Board finds that the schedular rating criteria for hearing loss is adequate to rate the Veteran's bilateral hearing loss, and referral for consideration of an extra-schedular evaluation is not warranted. See 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 115; VAOPGCPREC 6-1996. Lastly, an inferred claim for a total disability rating based on individual unemployability (TDIU) has not been raised by the Veteran or the evidence of record. When asked about the impact of his hearing impairment on daily life, including his ability to work, the only reported response from the Veteran on the August 2013 VA audiological examination report was "hard hearing." Therefore, the Board finds that the issue of entitlement to a TDIU has not been reasonably raised by the record or by the Veteran. See Rice v. Shinseki, 22 Vet. App. 447 (2009). B. Service Connection Legal Criteria and Analysis for Skin Cancer 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). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as chronic in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013) (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). Here, the Veteran's skin cancer has manifested as basal cell carcinoma and squamous cell carcinoma, each a "chronic disease" listed under 38 C.F.R. § 3.309(a) (as "tumors, malignant"). See Dorland's Illustrated Medical Dictionary 290 (32d ed. 2012) (basal cell carcinoma is "the most common form of skin cancer, consisting of an epithelial tumor of the skin originating from neoplastic differentiation of basal cells"). Therefore, 38 C.F.R. § 3.303(b) applies to the Veteran's claim for service connection for skin cancer. Similarly, service connection will be presumed if either of these "chronic diseases" manifested within the first post-service year. See 38 C.F.R. §§ 3.307, 3.309. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 469. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). 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, 7 Vet. App. at 506. The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran is claiming service connection for skin cancer, which has manifested as basal cell carcinoma and squamous cell carcinoma. The Veteran's main contention is that he was exposed to Agent Orange during service in the Republic of Vietnam (Vietnam) and that this exposure is the proximal cause of his skin cancer. He has also claimed that his skin cancer may have been caused by sun exposure while in service. See December 2009 VA Form 21-4138. Initially, the Board finds that the Veteran is currently affected by the residuals of skin cancer. During the August 2013 VA skin examination, the examiner noted that the Veteran was "presumed to be cancer free" after surgical resection of basal cell carcinoma on his nose in November 2005 and squamous cell carcinoma on his left cheek in February 2011. Additionally, the Board finds that the Veteran was exposed to Agent Orange during service in Vietnam. The Veteran's DD Form 214 confirms that the he served in Vietnam from March 1969 through March 1970. Given such service, exposure to herbicides during active service is presumed. See 38 C.F.R. § 3.307(a)(6)(iii) (a veteran who served in Vietnam during the Vietnam era shall be presumed to have been exposure during such service to an herbicide agent). Similarly, based on the Veteran's credible testimony, the Board finds that the Veteran was exposed to sun while in Vietnam. See Layno, 6 Vet. App. at 470 (a veteran is competent to provide evidence of facts and circumstances that can be observed and described by a lay person). Regulations pertaining to Agent Orange exposure, which includes all herbicides used in Vietnam, provide that if a veteran served on active duty in Vietnam during the Vietnam era, the veteran is presumed to have been exposed to Agent Orange or similar herbicides. These regulations also stipulate the diseases, including some types of cancer, for which service connection may be presumed due to an association with exposure to herbicide agents. The only skin condition presumed to be caused by Agent Orange exposure is chloracne, for which the Veteran does not have a current diagnosis. Because neither basal cell carcinoma nor squamous cell carcinoma is listed among the Agent Orange-related diseases enumerated in 38 C.F.R. § 3.309(e), medical nexus may not be presumed as a matter of law. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (1994). The Board finds that the weight of evidence demonstrate that symptoms of basal cell carcinoma or squamous cell carcinoma were not chronic in service. Service treatment records do not include any complaints, treatment, or diagnoses of these conditions or any other skin conditions. Further, at the September 1970 service separation examination, the separation examiner's summary and clinical evaluations do not reflect any reported complaints, findings, or diagnoses related to a skin condition affecting, including basal and squamous cell carcinomas. For these reasons, the Board finds that symptoms of basal cell carcinoma or squamous cell carcinoma were not chronic in service. Similarly, the Board finds that weight of the evidence demonstrates that neither basal cell carcinoma nor squamous cell carcinoma symptoms have been continuous since service. As discussed above, the September 1970 separation examination report does not include any skin disorders. Following service separation, the first observation of cancerous symptoms was noted in a June 2005 VA Medical Center (VAMC) entry describing a nose legion. Surgery followed in October 2005, nearly 35 years after service separation in September 1970. While the record includes subsequent medical records, those records do not demonstrate that the symptoms of skin cancer have been continuous since service. Additionally, given the facts above, the Board finds that skin cancer did not manifest to a compensable degree within the first post-service separation year. The Board further finds that the weight of lay and medical evidence demonstrates that the Veteran's skin cancer is not related to service, including in-service exposure to herbicides. During the August 2013 VA skin examination, the examiner reviewed the Veteran's claims file, interviewed the Veteran, and performed a physical examination of the Veteran. The August 2013 VA skin examiner then opined that it was "less likely than not" that the Veteran's skin cancer was incurred in or caused by service. The rationale explains that sun exposure is the major risk factor for both basal cell and squamous cell cancers. The examiner then concluded that his cumulative lifetime sun exposure is "most likely a greater risk factor for skin [cancer] than the relatively short time spent in the military." While the examiner misstated the Veteran's period of service, the Board notes that the examiner erred on the side of greater in-service exposure by overstating the overall service time by six years (actual discharge: 9/22/1970; stated discharge: 9/22/1976) and time in Vietnam by one year. As such, the Veteran was not prejudiced by this error because it remains consistent with the examiner's rationale. During the August 2013 VA skin examination, the Veteran stated that exposure to Agent Orange may have caused his skin cancer. He also has asserted that skin cancer may have been caused by sun exposure in service. The Veteran is competent to observe the appearance of a skin disorder such as basal cell carcinoma or squamous cell carcinoma on his skin. See McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (a veteran is competent observe skin conditions such as boils, blotches, and rashes). However, the Veteran is not competent to diagnose skin cancer or provide a competent opinion as to the cause or etiology of such a condition. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2008) n. 4 (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). The etiology of the Veteran's skin cancer is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. As such, his statements relating skin cancer to Agent Orange and sun exposure in Vietnam are not entitled to any probative value. See Rucker, 10 Vet. App. at 74 (veteran is not competent to diagnose carcinoma or relate it to service). Thus, given the lay and medical evidence of record, the weight of the evidence does not support finding that the Veteran's skin cancer is related to service. As such, service connection for the disability is not warranted. In reaching this conclusion, the Board considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable in the instant appeal as the preponderance of the evidence is against the claim. Gilbert; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER An initial disability rating for bilateral hearing loss in excess of zero percent is denied. Service connection for skin cancer, claimed as due to sun exposure, is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs