Citation Nr: 1337757 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 11-00 255A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for diabetes mellitus Type II, claimed as due to exposure to herbicides in service. 2. Entitlement to service connection for gynecomastia, claimed as due to exposure to herbicides in service. 3. Entitlement to service connection for hypogonadism, claimed as due to exposure to herbicides in service. 4. Entitlement to service connection for blurry vision, claimed as secondary to diabetes mellitus. 5. Entitlement to service connection for depression. 6. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Robert C. Brown, Jr., Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muscogee, Oklahoma that in relevant part denied service connection for diabetes mellitus Type II and for blurry vision. Also on appeal is a July 2010 RO rating decision that denied the service connection for gynecomastia, hypogonadism, PTSD and depression. The Veteran testified before the undersigned Acting Veterans Law Judge in a videoconference hearing from the RO in June 2013. A transcript of his testimony is of record. In conjunction with the hearing he submitted private medical records with a waiver of initial RO jurisdiction; the Board has accepted this additional evidence for inclusion into the record on appeal. See 38 C.F.R. § 20.800 (2013). FINDINGS OF FACT 1. The Veteran is not shown to have been exposed to herbicides in service. 2. Diabetes mellitus was not incurred in service, was not manifested to a compensable degree within the first year after discharge from service and is not etiologically related to service. 3. Gynecomastia, hypogonadism and a disorder manifested by blurry vision are not etiologically related to service. 4. The Veteran is not clinically diagnosed with a depressive disorder. 5. Medical evidence is at least in equipoise to show the Veteran has PTSD that is due to a verified stressful event in service. CONCLUSIONS OF LAW 1. Diabetes mellitus Type II is not due to or aggravated by service, and incurrence during service may not be presumed. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). 2. Gynecomastia is not due to or aggravated by service. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 3. Hypogonadism is not due to or aggravated by service. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 4. A disorder manifested by blurry vision is not due to or aggravated by service. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 5. Depression is not due to or aggravated by service. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 6. PTSD is due to or aggravated by service. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (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 in this case was provided fully-compliant notice prior to the rating decisions on appeal. In any event, he 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), service personnel records and post-service treatment records from those VA and non-VA providers the Veteran has identified as having treatment records that could be relevant to the issues on 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. The Veteran has been provided appropriate VA examinations in support of the claims herein decided. He was afforded a VA psychiatric examination in support of his claims for PTSD and depression, and he also submitted a private psychological evaluation on those issues that has been considered by the Board. The Veteran does not contend that the other claimed disabilities (diabetes mellitus, gynecomastia, hypogonadism or visual disorder) were directly incurred in service; rather, he asserts these claimed disorders developed after discharge from service and are related either to herbicide exposure in service or are secondary to claimed diabetes mellitus. As explained below, exposure to herbicides is not demonstrated and service connection for PTSD is not established. The Veteran has accordingly not presented a prima facie case for service connection and remand for VA examination is not required. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). See also Wells v. Principi, 326 F. 3d. 1381, 1384 (Fed. Cir. 2003); Duenas v. Principi, 18 Vet. App. 512 (2004) (per curiam). The appellant was afforded a hearing before the Board, during which he was represented by legal counsel. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the Veterans Law Judge (VLJ) who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the Acting VLJ identified the issues to the claimant and asked specific questions directed at identifying whether the appellant met the criteria for service connection. Additionally, the appellant volunteered his history and symptoms since service. The appellant 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, and the appellant provided testimony relevant to those elements. As such, the Board finds that no further action pursuant to Bryant is necessary, and the appellant is not prejudiced by a decision at this time. 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 Legal Principles Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes 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 diabetes mellitus 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 C.F.R. §§ 3.307, 3.309(a). Service connection for diabetes mellitus Type II is presumed when the veteran has been exposed to tactical herbicides, also known as Agent Orange, in service. 38 C.F.R. § 3.309(e). Exposure to herbicides is presumed for veterans who served in the Republic of Vietnam during the period beginning on February 28, 1961 and ending on May 7, 1975. The VA General Counsel has determined that this regulatory definition, which permits certain personnel not actually stationed within the borders of Vietnam to be considered to have served in that Republic, requires that an individual actually have been present within the boundaries of the Republic. Specifically, the General Counsel has concluded that in order to establish qualifying "service in Vietnam" a veteran must demonstrate actual duty or visitation in the Republic of Vietnam during the presumptive period. See VAOPGCPREC 27-97. 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 United States Court of Appeals for Veterans Claims (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 her 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 Diabetes mellitus, hypogonadism and gynecomastia As noted above, incurrence of diabetes mellitus Type II is presumed when exposure to herbicides in service is shown. There is no presumptive association between herbicide exposure and gynecomastia, hypogonadism or "blurry vision" (unless associated with diabetic retinopathy). The Veteran is shown to have served in Thailand as a member of the U.S. Army during the period June 21, 1967 to August 6, 1968. Exposure to herbicides may be conceded where an Army veteran provided perimeter security at specified Royal Thai Air Force bases anytime between February 28, 1961 and May 7, 1975. Exposure to herbicides may also be conceded for Army veterans who served on some small Army installations in Thailand during the same period, but the veteran must have been a member of a Military Police (MP) unit or have been assigned an MP occupational specialty whose duty placed him or her near the base perimeter. See VA Public Health Bulletin Thailand Military Bases and Agent Orange Exposure, February 22, 2012. The record does not reflect, and the Veteran does not contend, that he was stationed at any of the Royal Thai Air Force bases during his time in Thailand. Rather, he claims his duty station was Bang Pla and to have been quartered nearby at Bang Ping. He alleged that both compounds had cleared areas that were devoid of vegetation and that he was required to regularly work in the base perimeter and to go outside the compound to repair damage caused by thieves to the communication towers. He also alleges that because neither Bang Ping nor Bang Pla had assigned MPs, he had to perform regular perimeter patrols at both locations. During videoconference hearing before the Board in June 2013 the Veteran testified that while flying to Thailand from the United States his airplane landed for several hours in Saigon, Vietnam. He alleged that on two or three occasions he entered Vietnam to work on communications systems that needed maintenance; such travel was performed in State Department aircraft rather than military aircraft due to the sensitive nature of his duties. While in Thailand he observed local nationals spray weed killer around the compounds on which he lived and worked; he also had to perform "police call" cleaning up cigarette butts and other debris inside the compounds, and he voluntarily walked around the perimeter to ensure the camps were safe. On occasion he would go into the countryside to repair communications towers that had become inoperative because the local nationals had pilfered copper wire. As noted, the Veteran did not serve on any of the Royal Thai Air Force bases. The RO submitted a request to the Service Department via the Defense Personnel Records Information Retrieval System (DPRIS) for confirmation of possible exposure to herbicides in Thailand. The DPRIS response, dated in August 2010, states that the Veteran's unit Strategic Command Facility (STRATCOM) was located in Bangkok, where no herbicides were shown to have been sprayed. With respect to the Veteran's contentions that he performed the duties of an MP, the Veteran's records indicate that he served in the military occupational specialty (MOS) of machine accounts specialist. His duties were described as "fed information through computer for projects." To the extent that the Veteran may have occasionally performed duties of an MP or traversed the base perimeter, these activities do not rise to the level of daily or near-daily activities at or near the base perimeter to avail himself of the presumption. Turning to the Veteran's account of having been "in Vietnam" for purpose of availing himself of the presumption to herbicide exposure, the Board is not required to accept a veteran's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). However, if the Board rejects the Veteran's lay account of his history, the Board must indicate the reasons for so doing. 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. 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 Veteran is competent to report having occasionally been "in Vietnam." However, as noted in a Formal Finding by the RO in July 2010, the Veteran's service personnel record demonstrates service in Thailand but does not show service in Vietnam. Further, the file contains a Letter of Appreciation presented to the Veteran in July 1968 on the occasion of his redeployment from Thailand back to the United States; the letter praises the Veteran for his accomplishments in Thailand but is silent in regard to any activities having been performed by the Veteran in Vietnam. The Veteran is shown to have received both the Vietnam Campaign Medal and the Vietnam Service Medal, but these awards were presented to military personnel who served in Laos, Cambodia and/or Thailand during the Vietnam War and do not necessarily reflect actual service in Vietnam. Finally, the Board notes that the Veteran has been inconsistent in describing his duties and activities during military service. In a December 2009 statement, the Veteran indicates that he worked at a facility in Bangkok and worked with computers. He noted that he was exposed to Agent Orange because "my staff" went outside the perimeter to repair antenna cables. However, as noted above, in later statements, the Veteran claimed that he himself occasionally left the base to go out into the field to make repairs to equipment. 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 Veteran's personnel records and his own statements document his work on computer communications equipment. None of his personnel records mention any duties as an MP or performance of duties in the field, to include in Vietnam. The Veteran himself has been inconsistent in describing his duties, initially claiming his staff went into the field to make repairs, but later claiming he himself went into the field to make repairs, and alleging this is one of the ways he was exposed to Agent Orange. Although VA cannot dismiss a Veteran's contentions simply because he is an interested party, the Veteran's personal interest can affect his credibility. In this case, in light of the Veteran's inconsistencies regarding his description of his job duties, the lack of notation of any duties being performed in Vietnam, and the Veteran's own financial interest in his case, the Board finds the Veteran's statements of service in Vietnam to be not credible. Having found that the Veteran is not credibly shown to have been exposed to herbicides in service, the presumption of service connection does not apply and the Board turns to entitlement to service connection on a direct, rather than presumptive, basis. Service treatment records (STRs) are silent in regard to diabetes mellitus, gynecomastia or hypogonadism in service. The Veteran was noted in his induction physical to be overweight/obese, but this was not considered to be disabling. By the time of his separation physical examination he had lost 12 pounds. Urinalysis was negative for sugar at induction and at separation, and there is no indication of gynecomastia or hypogonadism in service. The Veteran presented for VA history and physical (H&P) examination as a new patient in February 2008. His only reported significant medical history was remote pneumonia in the 1970s. Thereafter the Veteran underwent a VA Agent Orange registry examination in March 2008 in which he stated that since return from Vietnam [sic] he had intermittent joint pains; he denied having been previously diagnosed with diabetes mellitus. He stated he had gynecomastia in 1998 and was found at the time to have testosterone deficiency, which was treated by testosterone injections. The examination is silent in regard to current gynecomastia or hypogonadism, but glucose tolerance was elevated and the Veteran was advised to see his primary care physician (PCP) regarding diabetes. In April 2008 the Veteran's VA PCP entered a clinical assessment of diabetes mellitus Type II. The Veteran had a VA diabetic teleretinal examination in July 2008 in which his visual acuity, uncorrected, was 20/20 in both eyes. Thereafter, he had a VA diabetic teleretinal examination in June 2009 in which his uncorrected visual acuity was 20/30 right eye and 20/50 left eye; the impression was borderline intraocular pressure (IOP) but no diabetic retinopathy and grossly normal examination bilaterally. The Veteran presented to the VA primary care clinic (PCC) in March 2010 complaining of nipple pain, originally manifested in 1993 and resolved at the time with testosterone injections. The Veteran requested a new series of testosterone treatments. The clinical impression was testosterone deficiency. Other current medical problems were listed as diabetes mellitus Type II, lipids, family history of low thyroid, concern for sleep apnea and concern for acute prostatitis. In June 2010 the Veteran's VA active problem list was amended to include hypogonadism. Other current active problems were listed as depression, benign prostate hypertrophy, sleep apnea, diabetes mellitus of unspecified type, hypercholesterolemia and chest pain. VA diabetic retinopathy surveillance consult in July 2011 was essentially normal. During videoconference hearing before the Board in June 2013 the Veteran testified he first became aware of gynecomastia at about 43 years of age when he developed pain in the nipples; after medical development he was told he had hormonal imbalance that he believes is due to exposure to herbicides in service. The Veteran testified that VA medical personnel had informed him gynecomastia and hypogonadism are characteristic of herbicide exposure, and he stated he believed he had blurry vision secondary to his diagnosed diabetes mellitus. STRs do not show, and the Veteran does not assert, that he had diabetes mellitus, gynecomastia, hypogonadism or vision problems in service. Per the Veteran's own account, gynecomastia and hypogonadism first became manifest in 1993, diabetes mellitus in approximately 2006 and vision problems some time thereafter. Thus, per the Veteran's account all his claimed disorders began 25 years or more after discharge from service. In that regard, the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection, particularly where, as here, the Veteran himself does not contend that the disorder became manifest until many years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Beginning with diabetes mellitus, the Veteran has a competent diagnosis of this disorder; accordingly, the first element of service connection - medical diagnosis of a claimed disability - is met. 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). Evidence of continuity of symptoms is for consideration in regard to disorders such as diabetes mellitus that are recognized as "chronic" under 38 C.F.R. § 3.309(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the Veteran in this case has not asserted continuous diabetes mellitus since service. As there is no evidence of diabetes mellitus in service or to a compensable degree within the first year of discharge from service, and as the presumption of exposure to herbicides is not applicable, service connection requires the competent opinion of a medical professional. Caluza, 7 Vet. App. 498. There is no such medical opinion of record, and absent an event in service, remand for medical examination with opinion is not necessary. See 38 C.F.R. § 3.159(c)(4). Hypogonadism is recorded on the Veteran's VA active problems list; gynecomastia is shown only by the Veteran's reported history. Neither disorder is documented in STRs, nor is either disorder shown by competent medical evidence to be etiologically related to service. Finally, in regard to claimed "blurry vision," there is no medical evidence of any diagnosed underlying disorder of the eyes. To the degree that the Veteran has refractive error, such error is not a disease or injury for which service connection can be considered; see 38 C.F.R. § 3.303(c). The Veteran has asserted his belief that he has blurry vision secondary to diabetes mellitus, but he is not shown to actually have diabetic retinopathy; in any event, since he is not service-connected for diabetes mellitus the Board cannot consider a claim for secondary service connection. Based on the evidence and analysis above the Board finds that diabetes mellitus, hypogonadism, gynecomastia and blurry vision are not incurred in or aggravated by service. Accordingly, the criteria for service connection are not met and the claims must be denied. Because the preponderance of the evidence is against the claims the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. Depression and PTSD Service connection specifically for PTSD "requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms an in-service stressor; and credible supporting evidence that the in-service stressor occurred." 38 C.F.R. § 3.304(f). Service personnel records show that while the Veteran was stationed in Thailand his major headquarters was STRATCOM in Bangkok. STRs show he was treated on August 19, 1967, for contusion of the left elbow incurred in a bus accident. STRs show no complaint of psychiatric problems during service. The Veteran's separation physical examination in August 1969 showed psychiatric evaluation as "normal;" in the corresponding self-reported Report of Medical History the Veteran denied depression or excessive worry or nervous trouble of any sort. The Veteran presented for VA H&P examination as a new patient in February 2008. He explained he had lost his job two years before and had been under stress since then; just talking about job stress caused his chest to feel tight. The Veteran presented to the VA PCC in March 2010 to follow up his diabetes mellitus. He reported being currently retired on Social Security and working on church projects as a volunteer. He complained of lack of interest in pleasurable activity. The clinician stated that the Veteran's depression and PTSD screen was positive and prescribed a medication to improve the Veteran's mood; the Veteran was referred to the PCC for appropriate follow-up. In June 2010 the Veteran's VA active problem list was amended to include "depression." In January 2011 the Veteran submitted a Statement in Support of Claim in which he recounted that while serving in Thailand he was a passenger in a bus that crashed while transporting persons who were between their work shifts. He stated that several persons who were sitting in his usual seat near the front of the bus were killed, while many others were injured; the Veteran himself, who suffered only bruises, helped to clear injured persons out of the bus immediately after the crash. The Veteran reported having but felt bad for having lost friends while he was spared. He also reported stress due to the responsibility of his job and due to fear of being attacked. In support of the bus stressor he submitted two undated newspaper articles alluding to a fatal bus crash in which two Americans were killed, as well as the Thai bus driver. The Veteran also submitted several photographs of a bus marked STRATCOM that had obvious heavy damage to the right front side. The RO submitted a DPRIS request for confirmation of the crash. The April 2011 response from DPRIS states that one of the bus crash victims identified by the Veteran was documented to have died on August 19, 1967, and the other victim named by the Veteran was documented to have died the following day. The RO indicated in a marginal note that this response appeared to confirm the Veteran's reported stressor. The Veteran had a VA psychiatric examination in April 2012, performed by an examiner who reviewed the claims file. The examiner noted that the Veteran was shown to have been involved in a "horrific" bus crash in service that met Criterion A for diagnosis of PTSD (the Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others). However, he did not meet Criterion B because the traumatic event was not persistently re-experienced; he did not meet Criterion C because there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness; and, he did not meet Criterion D because there were no persistent symptoms of increased arousal. Further, the Veteran had none of the symptoms associated with PTSD diagnosis. The examiner stated the Veteran did not have Axis I diagnosis of PTSD or any other psychiatric disorder. Under the field of "occupational and social impairment" the examiner checked the box indicating that a mental condition had been formally diagnosed but symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. Because this appeared to be inconsistent with the finding on examination of "no diagnosis" the RO asked the VA examiner to clarify whether the Veteran actually had a diagnosed mental condition, and if so whether such diagnosis was related to the Veteran's confirmed stressor of being involved in a bus accident. In response, the examiner provided an addendum stating that because the Veteran reported having been prescribed medication, a "mental condition that is unknown" had been diagnosed, but that symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. The RO noted that the addendum opinion appeared to still assert the Veteran had a diagnosed mental condition, and requested clarification of that question. The examiner thereupon provided another addendum stating explicitly that the Veteran did not have a psychiatric diagnosis. The Veteran was examined in November 2012 by Dr. Michael Stephen, a private psychologist who reviewed the claims file. Dr. Stephen recorded intrusive recollections, nightmares, flashbacks and avoidance behaviors, all related to the bus accident in Thailand. Dr. Stephen also recorded diminished interest in pleasurable activities, difficulty being in crowds, social isolation, difficulty trusting others, sleep problems, depression, anxiety, suppressed anger, memory and concentration problems, hypervigilance, hyperstartle, loss of motivation and some suicidal ideation. The Veteran reported other generalized anxieties in service, such as fear of possible enemy attack, but Dr. Stephen stated these were clinically less significant than the bus accident. When pressed by Dr. Stephen the Veteran admitted to post-service stressors including the recent deaths of people he knew and job-related experiences. Dr. Stephen diagnosed PTSD and associated that diagnosis with the traumatic incident in service. The Board finds at the outset that the Veteran's reported in-service stressor, the bus crash, is verified. The DPRIS response shows that there was a severe bus crash on August 19, 1967, which resulted in three fatalities (counting the bus driver), and STRs demonstrate that the Veteran was involved in a bus accident on that date. The Veteran's submission of photographs of the crashed bus further supports his contention of having been personally involved in the crash. The remaining question before the Board is whether the Veteran has an acquired psychiatric disorder, however diagnosed, that is consequent to that accident. The Veteran is noted on VA treatment records to have clinical evidence of "depression" as a symptom, but there is no formal psychiatric diagnosis of major depressive disorder (MDD), depressive disorder not otherwise specified (NOS) or any other depressive disorder despite multiple psychiatric evaluations. Accordingly, diagnosis of "depression" is not shown and service connection for such disorder may not be considered. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Turning to PTSD, the medical evidence of record contains conflicting diagnoses. The VA examiner and Dr. Stephen both apparently accepted the Veteran's account of the bus accident as credible, but the VA examiner diagnosed no current psychiatric disorder whatsoever whereas seven months later Dr. Stephen diagnosed PTSD based on that accident. If a veteran has received an "unequivocal" diagnosis of PTSD from a competent medical professional, VA must assume that the diagnosis was made in accordance with the appropriate psychiatric criteria in regard to the adequacy of the symptomatology and the sufficiency of the stressor, and can only reject such a diagnosis on a finding that the preponderance of the evidence is against the PTSD diagnosis, the occurrence of the in-service stressor, or the connection of the current condition to the in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 153 (1997). It is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). Further, the Board is not competent to make any inferences as to medical etiology, or degree of disability as to a claim for benefits, without a solid foundation on the record, grounded in medical evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). The Board in this case has no reason to question Dr. Stephen's diagnosis of PTSD. Cohen, supra. Further, the opinions expressed by the VA examiner and by Dr. Stephen appear to be equally probative under the criteria of Nieves-Rodriguez. Thus, the medical evidence is at least in equipoise in showing that the Veteran has PTSD due to the verified stressor in service (bus accident in Thailand). Based on the evidence and analysis above the Board finds the Veteran as likely as not has PTSD that is due to a stressful event in service. Accordingly, with resolution of the doubt in the Veteran's favor on this issue, the criteria for service connection for PTSD are met and the Veteran's appeal is granted to that extent. ORDER Service connection for diabetes mellitus Type II is denied. Service connection for gynecomastia is denied. Service connection for hypogonadism is denied. Service connection for blurry vision is denied. Service connection for depression is denied. Service connection for PTSD is granted. ____________________________________________ M. N. HYLAND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs