Citation Nr: 1340426 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 08-08 840 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for arthalgia and neurological impairment of the left side of the body, to include chest pain, left hand numbness, and left foot numbness, claimed as manifestations of an undiagnosed illness. 2. Entitlement to service connection for syncope, claimed as a manifestation of an undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and G.P. ATTORNEY FOR THE BOARD L. McCurdy, Associate Counsel INTRODUCTION The Veteran served for numerous years in the National Guard. He had active service from December 1972 to April 1973 and from November 1990 to May 1991. His second period of active duty service included service in the Southwest Asia theater of operations. The Veteran specifically asserts that his claimed conditions are related to his period of Gulf War service so the Board with focus its analysis on his second period of active service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which denied entitlement to the benefit currently sought on appeal. In December 2008, the Veteran and G.P., his wife, testified at a Video Conference hearing held before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The Board remanded these issues in September 2009 for further development by the RO which was completed. The Board again remanded these issues in March 2012 for the RO to obtain the Veteran's Social Security Administration records. The requested development has been completed and the RO issued a Supplemental Statement of the Case in October 2012. Thereafter, the case was returned to the Board for further appellate action. FINDINGS OF FACT 1. Arthalgia and neurological impairment of the left side of the body, to include chest pain, left hand numbness, and left foot numbness are traceable to diagnosed disabilities and are not attributable to service. 2. Syncope is traceable to a diagnosed disability and is not attributable to service. CONCLUSIONS OF LAW 1. The criteria for service connection for arthalgia and neurological impairment of the left side of the body, to include chest pain, left hand numbness, and left foot numbness, claimed as manifestations of an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). 2. The criteria for service connection for syncope, claimed as a manifestation of an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, including medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, this notice must address the downstream elements of disability rating and effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA's duty to notify was satisfied by way of a letter sent to the Veteran in November 2006 prior to the rating decision in February 2007. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 S. Ct. 1692 (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 Board finds that the notice requirements pertinent to the issues on appeal have been met. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of service and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records are of record and the RO assisted him in obtaining post-service treatment records and any indicated available private treatment medical records. Pursuant to the September 2009 remand directives, VA provided medical examinations regarding the claimed conditions in November 2009, February 2011, and May 2011. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As the requested exams were conducted by competent clinicians who considered the Veteran's claims file and medical history in their reports and provided pertinent information to include either etiological opinion, complete with rationale, or detailed report of current manifestations, the Board finds that such examinations and opinions are adequate to adjudicate the Veteran's claims. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran also noted that he was receiving Social Security Administration (SSA) disability benefits. Pursuant to the March 2012 remand directives, the RO obtained copies of the Veteran's SSA records and they have been associated with the claims file for review. These records were reviewed and relevant information is discussed in the decision. Moreover, as already noted, the Veteran and his wife were provided an opportunity to set forth their contentions during a hearing before the undersigned Veterans Law Judge (VLJ). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or VLJ who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the December 2008 hearing, the undersigned VLJ identified the issues on appeal. Also, information was solicited regarding the alleged onsets of the Veteran's disabilities, his post-service history of disability, and whether there was anything else that the Veteran wanted to say about his disabilities. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issue material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the undersigned VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to establish direct service connection for a claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Because the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, service connection also may be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for (1) a Persian Gulf Veteran who (2) exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; which (3) became manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1) (2013); see also Neumann v. West, 14 Vet. App. 12, 22 (2000), vacated on other grounds, 14 Vet. App. 304 (2001) (per curiam order). Section 3.317 explicitly acknowledges that a claimant's "signs or symptoms" need not be shown by medical evidence; however, the regulation does specifically require some "objective indications" of disability. See 38 C.F.R. § 3.317(a). "Objective indications of chronic disability include both 'signs,' in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical, indicators that are capable of independent verification." 38 C.F.R. § 3.317(a)(2). Thus, although medical evidence of signs or symptoms is clearly not required to grant a claim, the regulation does require that there be some objective, independently verifiable evidence of the symptoms. Id. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A § 1117(d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. A "medically unexplained chronic multi-symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Compensation shall not be paid under this section if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. § 1110 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran claims, in essence, that his disabilities are attributable to his participation in the Persian Gulf War in 1991. He maintains that his symptoms are the result of exposure to "environmental elements" and/or the various vaccines he received during service. There is no dispute that the Veteran served in the Southwest Asia theater of operations from January 1991 to May 1991. During the Veteran's October 1990 Retention Examination, the examiner's medical findings were all normal. The Veteran did indicate dizziness/fainting on his Report of Medical History in October 1990, but did not have periods of unconsciousness, loss of memory, or amnesia. He also indicated that he suffered from chest pain. The Veteran also complained of "frequent dizzy spells" on a Health Questionnaire for Dental Treatment in December 1990. However, the Veteran's separation examination in April 1991 was absent for any indication of symptoms of syncope or arthalgia and he was found medically normal upon release. The Veteran's July 1993 VA treatment records show that he complained of "chest wall muscular pain" but radiology records from later that month found that the Veteran had a "normal chest" and there was "no evidence of effusions or failure." The VA examiner noted that "chest x-ray was within normal limits and physical exam was essentially negative except for some chest wall tenderness." In August 1997, the Veteran complained of joint pain and stomach pain. He was found to have GERD. The Veteran was also treated in February 1999 because he could "hardly lift [his] left arm." The examiner found that he had a "chronic shoulder problem" and also noted that the Veteran had GERD (gastroesophageal reflux disease) symptoms. In March 1999, the Veteran had a physical therapy consult during which he complained of "pain in left shoulder." The pain was "non-radiating" but there was "occasional numbness along medial aspect of left under elbow, along ring and little finger." He was discharged from physical therapy in May 1999 after reporting that he had "decreased pain in [his] left shoulder." He again was treated in November 1999 because his "left shoulder [was] bothering him" and the examiner found the Veteran's "GERD stable." In August 2000, VA treatment records show that the Veteran complained of "dizziness when he bends over" that he attributed to his blood pressure. The examiner stated that the Veteran was to continue taking his blood pressure medication. In November 2000, the Veteran was seen complaining of chest pain and a "loss of balance due to dizziness." In December 2000, the Veteran complained of "pain posterior thighs to feet bilateral for last 2 months" and his "feet being cold." In January and February 2006, the Veteran was treated for carpal tunnel and during his follow-up after surgery, reported "return of sensation" to his left hand. In April 2006, the Veteran reported "blacking out" six times "since June 2005." He went on to complain of "left hand and left foot pain chronic" that worsened with his falls. The examiner diagnosed syncope and stated "unsure about etiology" but wanted to "rule out neuro cardiogenic syncope or some type of arrhythmia." In May 2006, the Veteran was treated for syncope, stating that he "had at least 4 episodes of syncope (witness)." Additionally, he reported that he "had witnessed syncope on a job site" and it "always occurs with standing." The Veteran underwent a cardiac arrhythmia "tilt test" procedure with normal findings. The examiner stated that the Veteran's "workup has been very good but inconclusive" and suggested a "reveal monitor" which also came back negative. An August 2006 Mental Status Evaluation and Evaluation of Adaptive Functioning recounted the Veteran's syncope history, which recounted that "[h]is [syncope] symptoms began inexplicably in July 2005." The Veteran submitted a July 2009 letter from his private physician, Dr. M.B., who indicated that he reviewed the Veteran's records and opined that "it is at least as likely as not that his syncope and neurological defects with left sided numbness and weakness are a result of his service." However, there was no rationale provided for this opinion. During a VA examination in October 2009, the examiner stated that the etiology of the Veteran's syncope and arthalgias could not be determined "without resort to mere speculation." The examiner noted that the syncope had an "unknown etiology" but "could be related to his sleep apnea." Additionally, the arthalgias had an "unknown etiology" but were "most likely DJD from an ageing process." During a VA examination in February 2011, the Veteran gave a history of carpal tunnel in 2006 in his left hand. Additionally, the Veteran reported a laceration with cellulitis and abscess formation in the left elbow in 2005. He also indicated that he "fell from a trailer and landed on his left buttocks on a fork truck sustaining a contusion to his sciatic nerve" in the 1970s. He was subsequently offered surgery but declined. The examiner noted that the Veteran had a cardiac event monitor for 14 months but that no cardiac events were noted despite the Veteran's episodes of syncope during that time. In February 2008, the Veteran was diagnosed with non-Hodgkin's lymphoma. The examiner again stated that the etiology of the Veteran's syncope could not be determined "without resort to mere speculation" because there was an "extensive workup for the veteran's syncope including 14 months of an implanted cardiac even monitor that failed to register cardiac pathology during these events, multiple normal stress tests, two normal echocardiograms, normal CTs of the head, normal tilt test, normal MRA of circle of willis, normal EEGs, normal Holter monitor, etc." The examiner stated that the "workup has been entirely negative" and the "episodes of syncope appear to be tentatively attributed to orthostatic dizziness from the veteran's HTN and BPH medications." Additionally, the examiner found that the Veteran's chest pain is due to "a combination of his non-Hodgkin's Lymphoma which is infiltrative into and around the thoracic organs, his grade IV esophagitis with chronic GI reflux...and his cholelithiasis s/p cholecystectomy in 2006." The examiner also noted that the Veteran "has multiple other issues which can cause noncardiogenic chest pain." Finally, the examiner found that the etiology of the Veteran's left hand and foot numbness "include a combination of bilateral carpal tunnel syndrome, and intermittent chemotherapy effect from the treatment of the Veteran's NHL." The Veteran's foot numbness in 2005 was attributed to "a peripheral neuropathy from his then alcohol usage (which has since ceased)." In an addendum dated in April 2011, the examiner stated that "the veteran's current disabilities did not begin during or occur as a result of the veteran's period of active military service in Southwest Asia." During a VA examination in May 2011, the examiner found that the Veteran's "syncope appears to be orthostatic and vagal in etiology" which was "most likely due to a combination or irritation of the vagal nerve in the thorax, related to his scarring, pleural effusions and B-cell cancer." Additionally, the examiner stated that "orthostatic hypotension due to blood pressure and prostate medications possibly made worse by autonomic neuropathy may also play a role." The examiner concluded that it was "less likely than not that the patient's syncope was caused by his service in the military" and went on to state that the "syncope occurred many years later, and appears to be well explained by his known medical conditions including medications for hypertension and prostatic hypertrophy as well as his pulmonary disease." The examiner stated that the Veteran's "arthalgias and chest pain appears to be well explained by his known gastroesohpageal reflux, esophageal varies, esophageal strictures, and his lung disease, as well as by his B-cell tumor that has infiltrated thoracic organs." He went on to note that the Veteran's "hand numbness seems well explained by his carpal tunnel syndrome and peripheral neuropathy" and that his foot numbness "was first reported in 2005 and is "likely due to peripheral neuropathy due to his previous history of heavy alcohol use (which has since stopped) as well as (more recently) as a side effect of the chemotherapy used for treatment of his Bcell tumor." The examiner concluded that it was "less likely than not that the patient's arthalgias, chest pain, hand numbness or foot numbness were caused by his service in the military." He explained that the "symptoms began many years later and are well explained by his other medical illnesses." Dr. M.B. referred the Veteran for a neuropsychological evaluation by Dr. G.C. in July 2011, who noted "no physical findings on...exam." Dr. G.C. indicated that the Veteran "would like [him] to write a letter for disability to the VA stating that Desert Storm caused his problems" but that he was "unable to do so." The Veteran submitted an additional letter from Dr. M.B. dated in October 2012 indicating that after a review of the records and a physical examination, it was "still his opinion" that the Veteran's "lower extremity neuropathy" was a result of "his exposure to burning oil fumes, Saran gas exposure, and subsequent Acetylcholine administration by military personnel during the period of 1990-1991 while serving in the Gulf war." Again, however, there was no accompanying rationale. In December 2008, the Veteran and his wife testified at a Video Conference hearing. The Veteran's representative conceded that the Veteran "was not treated for [his disabilities] in service" nor were they diagnosed in service but that they were due to an "undiagnosed illness." The Veteran also confirmed that he received a "report from the Assistant Secretary of Defense from Washington, D.C. on the Pentagon about 2005" that stated there were "low levels of chemical warfare agents" in the area where the Veteran was placed. The Veteran's wife testified that she is a nurse and believed the Veteran's conditions were linked to his service, including the vaccinations he was given while in the Gulf that were not approved by the FDA. Based on the evidence of record, the Board finds that service connection for syncope and arthalgias, claimed as due to undiagnosed illnesses, is not warranted. Although the Veteran and his wife attribute his conditions to his service, the greater weight of the evidence of records indicates that the Veteran's symptoms have, at least partially, conclusive pathophysiologies or etiologies attributable to diagnosed conditions. As explained by the VA examiners, the Veteran's syncope is explained by his "known medical conditions including medications for hypertension and prostatic hypertrophy as well as his pulmonary disease." His arthalgia and chest pain are linked to his carpal tunnel syndrome, alcohol use, and the chemotherapy used to treat his non-Hodgkin's lymphoma. In essence, since the Veteran's symptoms have been attributed to known clinical diagnoses, this precludes entitlement to service connection for syncope and arthalgias on a presumptive basis under 38 C.F.R. § 3.317. With regard to direct service connection, the Veteran has current diagnoses of syncope and arthalgia/neurological impairment. However, even though the Board finds the Veteran's testimony about his symptoms of numbness in his left side, chest pain, and syncope credible and consistent with his post service treatment records, there is no documentation of treatment in service regarding these conditions. The Board has considered the Veteran's contentions of dizziness/syncope in service. However, such assertions are contradicted by the weight of the evidence, including the August 2006 SSA evaluation which recited the Veteran's account of his syncope starting in July 2005; and the Veteran's own hearing testimony that his current claimed conditions did not have an onset until after service. Additionally, the multiple negative opinions regarding a nexus weigh heavily against the Veteran's claims. Accordingly, service connection for syncope and arthalgia and neurological impairment on a direct basis also is not warranted. Thus, the preponderance of the evidence is against the claim for service connection for syncope and arthalgia and neurological impairment and, therefore, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Service connection for syncope is denied. Service connection for arthalgia and neurological impairment of the left side of the body is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs