Citation Nr: 1337318 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 08-26 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran had active service from March 1944 to May 1946. He died in August 2007, and the appellant is his widow. This matter came before the Board of Veterans' Appeals (Board) on appeal from an October 2007 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. A hearing before the undersigned was held at the RO in June 2010. The hearing transcript has been associated with the claims file. The Board remanded this case for further development in August 2010 and, in June 2011, issued a decision denying this claim on the merits. The appellant appealed from the denial of service connection for the cause of the Veteran's death. In an August 2012 Order pursuant to a Joint Motion for Remand, the Court of Appeals for Veterans Claims vacated that decision and remanded to the Board. As discussed below, the evidence is now sufficient for a full grant of the benefit sought. FINDINGS OF FACT 1. The Veteran died in August 2007 from coronary/respiratory insufficiency due to coronary artery disease, which manifested many years after service. 2. The Veteran's service-connected conditions at the time of death included anxiety disorder, evaluated as 100 percent disabling effective since October 2000. 3. The Veteran's service-connected anxiety disorder aggravated his cardiac disability so as to materially contribute to cause his death. CONCLUSION OF LAW The criteria to establish service connection for the cause of the Veteran's death have been met. 38 U.S.C.A. §§ 1110, 1310, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board's decision herein to grant service connection for the cause of the Veteran's death constitutes a full grant of the benefit sought on appeal. Therefore, no further action is necessary to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations. To warrant DIC based on service connection for the cause of the Veteran's death, the evidence must show that a service-connected disability was either a principal or a contributory cause of death. A disability will be considered the principal cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. A disability will be considered a contributory cause of death when it contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death; there must be not merely a casual connection, but a causal connection to death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. Service connection for the cause of death is generally to be determined on the same basis as service connection for compensation under Chapter 11 of 38 U.S.C.A. (38 U.S.C.A. § 1100 et. seq.). 38 U.S.C.A. § 1310(a). A service-connected disability is one that was incurred in or aggravated during active service, or may be presumed to have been incurred during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Here, the Veteran's death certificate lists the immediate cause of death as coronary/ respiratory insufficiency due to coronary artery disease. At the time of the Veteran's death, he was service-connected for multiple disabilities, including anxiety disorder that had been evaluated as 100 percent disabling effective since October 2000. He was not service-connected for coronary artery disease. The appellant does not argue that the Veteran's coronary artery disease is directly related to service, and the evidence does not establish any link to service. Rather, the appellant contends that the Veteran died as a result of his service-connected anxiety disorder. She testified in June 2010 that his symptoms of anxiety had worsened prior to his death, and that he had experienced heightened anxiety shortly before he died. As such, the appellant asserts that the Veteran's anxiety exacerbated his heart problems and, ultimately, caused his death. Post-service medical records show a long history of treatment for heart problems, which began a number of years after service, with multiple heart surgeries. He also had ongoing mental health treatment for symptoms of a service-connected anxiety disorder since the late 1980s. Two days prior to the Veteran's death in August 2007, a VA contact record indicates that his daughter reported that he was anxious because his spouse was in the hospital, and he was having difficulty breathing. In an August 2007 VA treatment record on the day of the Veteran's death, a VA psychiatrist stated that his service-connected psychiatric disability could have very likely been a major contributing factor in his death from coronary insufficiency. Nevertheless, a VA examiner opined in June 2010 that the Veteran's death was not caused by his anxiety disorder, citing numerous medical studies that found no significant correlation between stress and the presence of coronary artery disease or cardiac events. The examiner acknowledged that the Veteran's psychiatric disorder had a crippling impact on his life, but opined that it did not alter the Veteran's life expectancy by causing or leading to progression of his coronary artery disease. The appellant subsequently submitted additional treatment records dating from 1987 through the date of the Veteran's death. The Board sought an opinion from a specialist in internal medicine with the Veterans' Health Administration (VHA) as to whether the Veteran's death was hastened by his service-connected psychiatric disorder, or was otherwise related to service based on the evidence of record. In an August 2013 report, the VHA specialist opined that it was at least as likely as not that the Veteran's service-connected psychiatric disorder, including the anxiety he was experiencing prior to his death, aggravated his cardiac disability so as to cause, hasten, or contribute to his death. The specialist stated that this rationale for this had become clear and well-supported in medical literature as set forth in an April 2013 comprehensive discussion by Dr. D. Many studies published in peer-reviewed literature show a positive correlation between psychiatric stress (such as anxiety) and coronary artery disease, cardiovascular disease, and early mortality. The specialist stated that the Veteran's medical records and evidence from his daughter and widow clearly described an increasing level of anxiety and worsening of his psychiatric condition in the months prior to his demise. The specialist noted that the June 2010 VA examiner's opinion did not include significant medical literature studies dated from 2007 to 2010 pertaining to stress, psychiatric illness, and their correlation with increased incidence of coronary disease. He also stated that current scientific data refused that VA examiner's opinion. The Board finds that the 2013 VHA specialist's opinion is highly probative, as it reflects consideration of all pertinent lay and medical evidence, and is supported by well-reasoned rationale based on medical expertise and experience, as well as consideration of medical opinions by other pertinent specialists. As such, this opinion outweighs the June 2010 VA examiner's negative opinion, which did not consider all pertinent literature, as noted by the specialist. Therefore, when resolving reasonable doubt in the appellant's favor, the evidence establishes that the Veteran's service-connected anxiety disorder materially contributed to cause his death. As such, service connection is warranted for the cause of the Veteran's death, and the claim is granted. 38 C.F.R. §§ 3.102, 3.312. ORDER Service connection for the cause of the Veteran's death is granted. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs