Citation Nr: 1337131 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 09-24 093 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a bilateral hearing loss disability. 2. Entitlement to service connection for an autoimmune disorder. 3. Entitlement to service connection for ulcerative colitis/inflammatory bowel disease (IBD). 4. Entitlement to service connection for arthritis, claimed as secondary to a digestive disorder. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL Appellant and his Spouse ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from June 1960 to June 1964 and from November 1965 to September 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon that in relevant part denied service connection for hearing loss. Also on appeal is a September 2009 rating decision that denied service connection for ulcerative colitis/IBD, arthritis and an autoimmune condition. The Veteran and his spouse testified before the undersigned Veterans Law Judge in a hearing at the RO ("Travel Board" hearing) in August 2011. A transcript of their testimony is of record. In September 2012 the Board remanded the issues identified on the title page for further development, which has been accomplished. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Bilateral hearing loss disability did not become manifest during service or to a compensable degree within the first year after discharge from service and is not etiologically related to service. 2. Arthritis, an autoimmune disorder to include lupus erythematosus, and ulcerative colitis/IBD did not become manifest during service; neither arthritis nor lupus erythematosus became manifest to a compensable degree within the first year after discharge from service; and not one of the Veteran's disorders is etiologically related to service, or caused, or permanently worsened, by any service-connected disability. CONCLUSIONS OF LAW 1. Bilateral hearing loss disability was not incurred in or aggravated by active service and sensorineural bilateral hearing loss may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2013). 2. An autoimmune disorder was not incurred in or aggravated by service, nor may lupus erythematosus be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 3. Ulcerative colitis/IBD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 4. Arthritis was not incurred in or aggravated by service and was not proximately caused or aggravated by service-connected disability, nor may incurrence in service of arthritis be presumed. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VA must also notify the claimant that, should service connection be awarded, a disability rating and an effective date for the award of benefits will be assigned. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided compliant notice prior to the rating decisions on appeal, to include the criteria for service connection on a direct and secondary basis and the effective-date and disability-rating elements of a service connection claim. In any event, the Veteran has not identified any prejudice due to error in the content or timing of the notice provided. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The RO has obtained service treatment records (STRs) and all available post-service treatment records identified by the Veteran. In that regard, the Veteran has asserted there are additional treatment records from various military installations that are missing from his record and should be obtained; however, as documented in an August 2009 memorandum, the RO conducted a diligent search that produced no additional service records, so remand for further pursuit of such records would be futile. Remands that would only result in imposing additional burdens on VA, with no benefit flowing to the claimant, are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Further, VA has no duty to seek to obtain that which does not exist. Counts v. Brown, 6 Vet. App. 473, 477 (1994); Porter v. Brown, 5 Vet. App. 233, 237 (1993). In that regard, the Veteran asserts his cited missing service treatment records were destroyed in a fire at the National Personnel Records Center (NPRC) in 1973. The Board notes that the 1987 NPRC fire destroyed 85 percent of records for Air Force veterans with surnames Hubbard through Z who served from September 25, 1947 through 1963, and although this is within the time period of the Veteran's service his surname is outside the range of names affected. Given this discrepancy, and given that a full packet of STRs is associated with the file, the Board cannot conclude that any service records pertaining to the Veteran were destroyed in the 1973 NPRC fire. The Veteran was afforded a hearing before the Board. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the VLJ identified the issues to the Veteran and asked specific questions directed at identifying whether he met the criteria for service connection. Additionally, the Veteran volunteered his history and symptoms since service. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claims on appeal, and the Veteran provided testimony relevant to those elements. As such, the Board finds that no further action pursuant to Bryant is necessary, and the Veteran is not prejudiced by a decision at this time. The Board previously determined the medical opinion of record was insufficient in regard to the etiology of the Veteran's claimed disorders and remanded the case for additional examination and audiological evaluation, both of which were performed in October 2012. The Board has reviewed the examination reports and finds the RO substantially complied with the Board's remand directive. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board also finds that the medical evidence of record is now sufficient for the Board to adjudicate the appeal. Neither the Veteran nor his representative has made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and neither has argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced the Veteran in the adjudication of his appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the issues on appeal. Applicable Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Where a veteran served for at least 90 days during a period of war or after January 1, 1947, and manifests arthritis, lupus erythematosus or sensorineural hearing loss (SNHL) to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for disability that is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Under the revised § 3.310(b), effective since October 2006, secondary service connection is available for chronic aggravation of a nonservice-connected disorder. Generally, when a veteran contends that a service-connected disorder has caused or aggravated a secondary disability, there must be competent medical evidence of such causation or aggravation. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995); Jones v. Brown, 7 Vet. App. 134 (1994). To prevail on the issue of secondary service causation, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, supra. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Also, the threshold for normal hearing is between 0 and 20 decibels, and higher threshold shows some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The absence of evidence of a hearing disability during service (i.e., one meeting the requirements of 38 C.F.R. § 3.385 above) is not always fatal to a service connection claim. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). Hensley, 5 Vet. App. at 159. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The first inquiry is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA 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). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence and Analysis Service connection for hearing loss Service treatment records (STRs) show no complaint of hearing loss. The Veteran has an enlistment physical examination in June 1960 that showed hearing acuity to be 15/15, or normal under the "whispered voice" test. The Veteran was enrolled in the hearing conservation program, in conjunction with which he was administered audiometric evaluations in July 1960, October 1962, and March 1964; these tests appear to show essentially normal hearing. The Veteran also had separation physical examinations in April 1964 (first enlistment) and September 1966 (second enlistment) in which his audiometric scores that were essentially normal. In his claim for service connection, received in July 2007, the Veteran asserted his claimed hearing loss began in 1964. The Veteran had a VA audiological evaluation in December 2007, performed by an audiologist who reviewed the claims file and STRs. The Veteran reported that during service he worked in fire production, overhauled diesel engines at radar sites and worked as an operator in a power plant; no hearing protection was reported. He stated he flew often and was exposed to engine noise. After service he worked at a plywood plant for a year, worked as a mechanic on logging equipment for two years and worked as a welder for 30 years. He denied recreational noise exposure. The audiologist performed a hearing acuity evaluation, which showed hearing loss to a disabling degree under the criteria of 38 C.F.R. § 3.385. The audiologist diagnosed mild-to-severe SNHL in both ears. The audiologist noted that STRs included hearing tests in 1960, 1962, 1964, 1965 and 1966, all of which showed normal hearing in service. Based on this, it could only be concluded that the Veteran's hearing loss occurred after leaving the service and was not caused by noise exposure in service. The Veteran submitted a letter in January 2009 stating he had flown often in large helicopters and in fixed-wing aircraft that very noisy. He also reported working in powerhouses with loud engines running constantly, and being exposed to loud generators at radar sites. Also, he fired on the small arms range. During none of these noise exposures was he offered hearing protection. The Veteran had another VA audiological evaluation in October 2012, performed by the same audiologist who had performed the earlier evaluation cited above. The audiologist again reviewed the claims file and continued the previous diagnosis of bilateral SNHL. The audiologist stated an opinion that the Veteran's SNHL is not likely caused by or a result of an event in service. As rationale, the audiologist stated that hearing tests in service all showed hearing well within normal limits in both ears. There was no complaint of hearing loss during separation examination in September 1966, although other conditions were noted, and there is no pattern of progressive hearing loss over those years that is consistent with the claimed post-service hearing loss disability. The evidence clearly indicates the Veteran's hearing loss occurred after leaving service. In his most recent Statement in Support of Claim, received in June 2013, the Veteran asserted that his hearing tests during service were inadequate. He also stated that noise exposure is the most common cause for tinnitus, and since he is service-connected for tinnitus this should demonstrate entitlement to service connection for hearing loss. Review of the evidence of record shows the Veteran has diagnosed bilateral SNHL. Accordingly, the first element of service connection - medical evidence of a claimed disability - is shown. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military 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). As noted, service treatment records show normal findings with regard to the Veteran's hearing acuity. The evidence does not show that the Veteran's hearing loss had its onset in service. The Board has also considered whether service connection for SNHL may be granted on a presumptive basis under 38 C.F.R. § 3.309(a). However, given the Veteran's normal hearing at the time of his discharge from service and the absence of a diagnosis of hearing loss until many years after service, there is no basis on which the Board can conclude that he would have had hearing loss to a compensable degree within a year after his discharge. Additionally, the evidence fails to establish a nexus between the Veteran's hearing loss and service. The Veteran has been afforded two VA audiological evaluations during the course of the appeal that resulted in an opinion that the Veteran's hearing loss occurred after leaving the service and was not caused by noise exposure in service. The audiologist who performed both evaluations was informed of the facts and produced a fully-articulated opinion supported by reasoned analysis. The audiologist's opinion may accordingly be relied upon by the Board as probative of the issue on appeal; see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). Further, the opinion articulated by the VA audiologist is not contradicted by any other medical opinion of record. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498. Accordingly, in addition to the medical evidence above the Board has considered the lay evidence of record to include the Veteran's testimony before the Board, his correspondence to VA and his statements to various medical providers. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). In this case, the Veteran's lay testimony is offered to show exposure to significant acoustic trauma during service and a relationship between such noise exposure and his claimed hearing loss disability. The Veteran is competent to describe events in service, to include noise exposure; in fact, his occupational exposure to noise is demonstrated by his enrollment in the hearing conservation program. The Board accordingly finds the Veteran was exposed to loud noises during service. The Veteran also asserts that he had onset of hearing loss during service. To that degree, a layperson is also competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). 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. 498 (1995). 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). The Board may not ignore a veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits; personal interest may, however, affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board finds that Veteran's current report of having onset of hearing loss during service is not credible because it is inconsistent with STRs, which show by affirmative documentation that he did not have appreciable hearing loss. The Veteran has argued that on one occasion the audiological examiner in service recorded falsified scores (the Veteran characterized this as a "CYA" effort) but he has presented no reason for the Board to reject the objective medical evidence of record. Further, the VA audiologist considered the Veteran's STRs and found no significant pattern of hearing loss therein. To the degree that the Veteran asserts his personal opinion that his current hearing loss disability is related to noise exposure in service, this is a medical question of sufficient complexity to be beyond the competence of a layperson. Kahana, 24 Vet. App. 428. During the course of the appeal the Veteran has submitted several internet treatise articles in support of his claim, which essentially state that SNHL may be caused by exposure to loud noises. A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than unsubstantiated lay opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case, there is no medical opinion relating the general points made in the articles to the specific circumstances of the Veteran's case, and the Board finds the articles to be not probative. Based on the evidence and analysis above the Board finds the Veteran's bilateral hearing loss is not incurred in or aggravated by service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. Service connection for digestive disorder, autoimmune disorder and arthritis The Veteran's digestive and autoimmune disorders and his arthritis are etiologically related. In that regard, the Veteran submitted an article from the University of Oklahoma Health Center titled "Inflammatory Bowel Disease (IBD) Can Lead to Arthritis" stating that IBD and arthritis are both auto-immune diseases and need to be looked at as "co-existing" conditions that influence and contribute to each other rather than as separate unrelated illnesses. Similarly, a letter from Dr. Wasner, which was received by VA in January 2009, states the Veteran was being followed for IBD arthritis with a "lupus anticoagulant" and that the presumed etiology of this was his autoimmune state caused by IBD. Accordingly, these claimed disorders will be discussed together. STRs relating to the Veteran's first enlistment show no evidence of an autoimmune disorder, digestive disorder or arthritis. In a self-reported Report of Medical History, prepared in April 1964 in support of his separation examination, the Veteran denied history of frequent indigestion and denied history of stomach, liver or intestinal trouble, and the corresponding examination report shows evaluation of the abdomen and viscera as normal. In the same Report of Medical History, the Veteran denied history of arthritis/rheumatism and also denied history of swollen or painful joints, although he did endorse foot trouble. The corresponding examination report notes an impression of bilateral pes planus and history of fractured wrist but no other bone or joint abnormalities. STRs relating to the Veteran's second enlistment similarly show no evidence of an autoimmune disorder, digestive disorder or arthritis. An enlistment examination report in November 1965 and a separation examination report in September 1966 both show the musculoskeletal system (feet, spine, upper extremities and lower extremities) and abdomen and viscera as normal. Of note, in a self-reported Report of Medical History in September 1966 the Veteran specifically denied history of frequent indigestion or of stomach, liver or intestinal trouble and also specifically denied history of arthritis or rheumatism. Treatment notes by Drs. Hallett and Strutin include an October 1991 treatment note referring to history of ulcerative colitis for over 20 years. A history and physical (H&P) examination by Dr. Hallett in January 1993 noted ulcerative colitis as "clinically quiescent" and abdominal ultrasound in June 1993 and computed tomography (CT) of the abdomen in August 1995 were both normal. In July 1998 Dr. Hallett referred to history of ulcerative colitis for "at least 35 years) and urged surgery. The earliest indication of related joint problems is a treatment note in April 1999 showing the Veteran had developed recurrent arthralgias after being taken off prednisone following surgery for his ulcerative colitis the previous year (total proctocolectomy and ileo-pouch anastomosis). The initial impression in April 1999 was generalized arthralgias and probably some degree of arthritis that "could be" related to his ulcerative colitis history but this was later changed in November 2002 to "probable arthritis associated with ulcerative colitis." Subsequent treatment notes by Dr. Strutin in November 2007 show an impression of ulcerative colitis, basically cured surgically, but current chronic arthritis probably related to ulcerative colitis. Similarly, in November 2008 Dr. Strutin recorded a clinical impression of generalized arthritis of undetermined type, consistent with the Veteran's history of ulcerative colitis. The Veteran had a VA history and physical (H&P) examination in April 2008 in conjunction with establishing care at the VA primary care clinic (PCC). The Veteran reported having a significant history of ulcerative colitis and gastroesophageal reflux disease (GERD) that was diagnosed in 1965, at the same time as his diagnosis for rheumatoid arthritis. His past medical history was significant for total proctocolectomy with ilial pouch and anastomosis in 1999. Review of symptoms (ROS) noted subjective report of heartburn and diarrhea, both well controlled with medication; no pain, constipation or trouble swallowing; and, no black or tarry stools. Objective gastrointestinal examination was grossly normal. The clinical impression was GERD and ulcerative colitis, status post total proctocolectomy with ilial pouch and anastomosis. During the H&P examination cited above, the Veteran also reported he had recently been referred to a hematologist and been found to be positive for the lupus anticoagulant, for which he was taking warfarin by prescription. He further reported having a significant history of rheumatoid arthritis that was diagnosed in 1965, the same time as his diagnosis for ulcerative colitis and GERD. The current clinical impression was rheumatoid arthritis. The Veteran had a VA C&P examination in June 2008, performed by an examiner who reviewed the claims file. The Veteran reported that ulcerative colitis was diagnosed in 1966, although he had been having intermittent episodes of loss stools with blood and abdominal cramping for three or four years. One year after leaving service he began having weight loss. He also reported that when his ulcerative colitis first flared he had swelling of ankles, which resolved when he took medication for colitis. He developed increased abdominal pain the previous winter and was eventually diagnosed with a liver clot in March 2008, which resulted in a finding of abnormal blood clotting and consequent prescription for anticoagulant. Otherwise, the examiner made no further observations, diagnoses or clinical impressions in regard to digestive symptoms. During the June 2008 C&P examination cited above the Veteran reported that swelling of the ankles had become manifest when his ulcerative colitis first flared; the swelling resolved when he took medication for colitis, and he was told he had rheumatoid arthritis. There were no subsequent significant problems with the joints until 1999, when he went off the medication for colitis and began getting pains in the fingers and toes. Thereafter he was treated for joint pains with medication, intermittent steroid injections into the great toes and cortisone injections into the buttocks. He stated that his musculoskeletal problems were primarily in the fingers, wrists, ankles and toes. The examiner performed a clinical examination and noted observations in detail. The examiner diagnosed rheumatoid arthritis of the hands, feet, ankles and wrists. The examiner stated that the Veteran reported having been diagnosed with rheumatoid arthritis by a podiatrist one year after discharge from service, but without a report by that podiatrist or a current rheumatology report it would be mere speculation to determine if the evidence showed rheumatoid arthritis during service. A VA X-ray in June 2008 showed severe degenerative disease in the first metacarpal phalangeal (MP) joint of both feet. The Veteran submitted a Statement in Support of Claim in January 2009 asserting that while assigned to duty at Sheppard Air Force Base in service he developed severe cramping and had to be transported to the hospital. He also submitted a letter in January 2009 reiterating that he had been hospitalized for abdominal cramping during basic training, and also that he had episodes of vomiting and rectal bleeding while assigned to Alaska during his first enlistment. The Veteran's wife submitted a letter in January 2009 in which she stated she had married the Veteran in December 1965; he was having recurrent stomach and bowel problems that continued after his discharge. The Veteran was eventually diagnosed with nonspecific ulcerative colitis. Similarly, the Veteran's mother-in-law submitted a letter to VA in April 2009 asserting that she became aware of the Veteran's ulcerative colitis problems at the time of his separation from service (second enlistment) in 1966. At one point in 1967 the Veteran's ulcerative colitis was so severe as to be life-threatening. In July 2009 the Veteran submitted a letter to VA clarifying that he had not been hospitalized at Sheppard Air Force Base for abdominal cramps, but rather had been treated on an emergency basis at the base hospital for stomach cramps but was released after some tests because the cramps had resolved and nothing had been found to account for the cramps. He also asserted that his complete service medical treatment record was not available to VA and was presumed to have been destroyed during a fire at the National Personnel Records Center (NPRC) in 1973. Finally, the Veteran asserted that ulcerative colitis is difficult to diagnose and that in his case diagnosis came only after many months of testing. The Veteran had X-rays of the entire spine by Oregon Imaging Center in March 2009 that showed multilevel DDD and moderate osteoarthritis of the lumbar spine; moderate diffuse osteoarthritis of the thoracic spine; and, mild DDD and mild diffuse osteoarthritis of the cervical spine. Treatment notes from Willamette Valley Cancer Institute dated in April 2009 show diagnosis of lupus anticoagulant and portal vein thrombosis as secondary to lupus anticoagulant. The Veteran testified before the Board in August 2011 that he was stressed during Air Force basic training by drill instructors who kept yelling at trainees and rushing them through meals. He developed stomach cramps during basic training, which on one occasion were so bad he was taken by ambulance to the base hospital, where nothing could be clinically established. Subsequently during duty in Alaska he had bleeding, but this was dismissed as nothing worse than bleeding hemorrhoids. Also, the food at that installation was terrible and caused indigestion. The Veteran had a break in service, was married, and then reenlisted; during his second enlistment he did not have many medical problems until toward the end; he obtained a discharge because he was not reinstated in his former rank as he had been promised, which was stressful. Following discharge from service the colitis got progressively worse and resulted in unremitting bloody diarrhea within the first year after discharge. The Veteran's wife stated she remembered the Veteran being very sick during the period 1966-1967. The Veteran submitted a letter to VA in August 2011 asserting that his varicose veins in service may have been early manifestations of an autoimmune disorder. He asserted that while assigned to duty in Alaska he had frequent episodes of vomiting and rectal bleeding, which was dismissed at the time as hemorrhoids. He also cited stress during service (associated with being "yelled at" during Air Force basic training) as a possible source for autoimmune disorder. In sum, the Veteran asserted that all the problems he had in service (varicose veins, sore joints including the feet, stomach and bowel problems) were symptoms of an autoimmune disorder that were not diagnosed during service. Dr. Wasner submitted a letter to VA in October 2012 stating the Veteran has severe IBD of the ulcerative colitis type. In regard to when these conditions first manifest, it is entirely possible they may have been present during the Veteran's teenage years; the condition often presents during that time and the Veteran has brought records showing restriction of Achilles tendon in service, which is often a symptom of this type of illness. Dr. Wasner admitted he did not treat the Veteran prior to 1999, but a reconstruction of his history is certainly possible as we do understand the course and presentations of this major systemic illness. The Veteran had a VA examination in October 2012, performed by a physician who reviewed the claims file. The Veteran reported he was diagnosed with ulcerative colitis in 1966, not long after his discharge from service, although he had experienced intermittent loose stools, blood and abdominal cramping for 3-4 years before that. He reported having been told he has rheumatoid arthritis that is consequent to his ulcerative colitis, and he complained of pain in multiple joints. The examiner recorded the Veteran's medical history in detail and entered an impression of ulcerative colitis, stabilized on current medications. The examiner stated there were no medical records regarding intestinal problems or ulcerative colitis in the 1960s or 1970s available for review, and those STRs that are of record do not show complaint of gastrointestinal symptoms or problems during service. At his separation examination in September 1966 the Veteran characterized his health as "good" and indicated "no" to any indigestion, stomach/liver/intestinal trouble or piles/rectal disease. With currently available information, it is not likely the Veteran had signs, symptoms or other indications in service of his later gastrointestinal problems and ulcerative colitis, and it is unlikely the Veteran has IBD as a result of service. Further, without documentation from the 1960s or 1970s for review, it would be speculative to date the onset of IBD. In regard to joint disorders, current X-ray showed hypotrophic arthritis and degenerative disc disease (DDD) in the spine, erosive arthritis and degenerative arthritis of various joints in the hands and degenerative arthritis in various joints of the feet. The examiner diagnosed IBD arthritis, osteoarthritis of the hands and degenerative changes of the spine. The examiner stated an opinion that the Veteran did not likely have inflammatory joint disease of the feet during service or resulting from service. With currently available information, the Veteran does have inflammatory arthritis associated with and secondary to his IBD, but as noted above it is unlikely the underlying IBD became manifest during service or is a result of service. The VA examiner cited above issued an addendum opinion in April 2013 in which he expanded upon the etiology of the Veteran's autoimmune disorder. The examiner noted that ulcerative colitis is an autoimmune disorder of the intestines; by definition, an autoimmune disorder is the result of a person's immune system responding to tissues within that person's body. The consensus in medical literature is that autoimmune disease is idiopathic. In the Veteran's case, there was no evidence of ulcerative colitis or autoimmune disease in the discharge examination or history, and no medical record or written documentation of onset of his intestinal symptoms or IBD in the 1960s or 1970s in the available record. Again, without such documentation it would be speculative to assign a date of onset of IBD in service or the first year after discharge from service. The examiner was unable to find evidence that the Veteran's ulcerative colitis can be attributed to his military service or by external factors during or after service. Similarly, the examiner was unable to find evidence of inflammatory arthritis in STRs, to include the Veteran's complaints of foot pain and flattened arch. With the currently available documentation it is not likely that the Veteran had arthritis that was manifested to a compensable degree within the first year after discharge from service, and to do so would be speculative. In his most recent Statement in Support of Claim, received in June 2013, the Veteran asserted that statements from his spouse and his mother-in-law, cited above, should be afforded great probative value in documenting symptoms during and immediately after service, citing McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). He also asserted he had not reported some of his digestive complaints at the time of his separation examination because he would not get treatment at that point and it was easier to mark "no" than to get into a discussion with the examiner. Review of the evidence above clearly shows the Veteran has a digestive disorder (ulcerative colitis/IBD) and associated inflammatory arthritis and autoimmune disorder. Review of the evidence also shows the etiology of such disorder is a complex question that requires medical expertise to resolve. The most complete and probative medical opinion of record is that of the VA examiner in October 2012 as supplemented by the addendum in April 2013. This opinion demonstrates the Veteran's immune disorder is not shown to have had its onset during service and is not shown to be related to service. The examiner was clearly informed of the facts and produced a fully-articulated opinion supported by reasoned analysis, and may be relied upon by the Board as probative of the issue on appeal. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). The VA examiner stated that it would be speculative to provide an opinion regarding the onset of the Veteran's current disorder, absent clinical records from the 1960s and 1970s. The Board may rely on a statement that an opinion cannot be provided without resort to "mere speculation" if it is clear that the procurable and assembled data was fully considered and the basis for the opinion is provided by the examiner or apparent upon a review of the record. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The Board has considered the October 2012 letter by Dr. Wasner, which states "it is entirely possible" the Veteran's autoimmune symptoms "may have been present" during his teenage years. The findings of a physician are medical conclusions that the Board cannot ignore or disregard. Willis v. Derwinski, 1 Vet. App. 66 (1991). However, the Board is free to assess medical evidence and is not obligated to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App 614 (1992). In this case, Dr. Wasner's statement is expressed in speculative language that does not provide the degree of certainty required for medical nexus evidence. Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Bostain v. West, 11 Vet. App. 124, 127-28 (1998). Further, the statements of medical professionals concerning a veteran's medical history related by the veteran as to remote events are of inherently less value than contemporaneous clinical records; see Harder v. Brown, 5 Vet. App. 183, 188 (1993). In this case, contemporaneous clinical records in the form of STRs affirmatively show the Veteran did not have symptoms upon entrance into service, during service, or upon separation from service consistent with an immune disorder, which renders the question of whether he had such disorder as a teenager (i.e., prior to service) irrelevant. The Board has considered the lay evidence offered by the Veteran, to include the lay statements offered by his spouse and his mother-in-law. These statements are intended to show the Veteran had severe ulcerative colitis within the first year after his discharge from service. A layperson is competent to testify in regard to observable symptoms. Layno, 6 Vet. App. 465, 469. Further, evidence of continuity of symptoms is for consideration in regard to disorders recognized as "chronic" under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, such "chronic" disorders include arthritis and lupus erythematosus. However, ulcerative colitis/IBD is not such a "chronic" disorder, and lay evidence of continuous symptoms since service, while probative, is not a sufficient basis for granting service connection in the absence of supporting medical opinion. To the degree that the Veteran and his spouse have reported intermittent epigastric symptoms during service, such reports do not demonstrate the onset of a chronic autoimmune disorder during service, particularly given that competent and uncontroverted medical opinion of record states an autoimmune disorder did not have its onset in service. During the course of the appeal the Veteran has submitted a number of internet medical treatise articles relating to ulcerative colitis and autoimmune disorders. These articles generally state that ulcerative colitis has no known cause; that ulcerative colitis may cause arthritis when the immune system triggers inflammation in other parts of the body; that ulcerative colitis is difficult to diagnose because its symptoms are similar to other intestinal disorders such as irritable bowel syndrome (IBS); and, that ulcerative colitis occurs most frequently in young adults and that persons with the disorder are generally asymptomatic between attacks. However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). In this case there is no supporting medical evidence that the general principles cited in the articles relate to the specific situation of the Veteran. Mattern, 12 Vet. App. 222, 228. Rather, the medical evidence that relates specifically to the facts of the Veteran weighs against his claims. Finally, considering entitlement to service connection for arthritis on a secondary basis, the Board has determined that the Veteran's autoimmune disorder with IBD is not etiologically related to service, so secondary service connection cannot be considered based on that disorder. The Veteran's only service-connected disabilities are tinnitus and flat feet, and there is no suggestion that arthritis is secondary to these disabilities. Thus, entitlement to service connection for arthritis on a secondary basis is denied as a matter of law. 38 C.F.R. § 3.310. In sum, based on the evidence and analysis above the Board finds the Veteran's autoimmune disorder, manifested by ulcerative colitis/IBD and inflammatory arthritis, was not incurred in, aggravated by, or in any way etiologically related to service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. ORDER Service connection for a bilateral hearing loss disability is denied. Service connection for an autoimmune disorder is denied. Service connection for ulcerative colitis/IBD is denied. Service connection for arthritis is denied. ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs