Citation Nr: 1328504 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 13-02 954 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a heart disability with a pacemaker. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for a hernia. 5. Entitlement to service connection for a back disability. 6. Entitlement to service connection for right upper extremity carpal tunnel syndrome. 7. Entitlement to service connection for left upper extremity carpal tunnel syndrome. 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). 9. Entitlement to non-service-connected pension benefits. WITNESSES AT HEARING ON APPEAL Appellant (Veteran) and his son ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from August 1945 to August 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. In May 2013, the Veteran and his son presented testimony relevant to the appeal at a Board hearing held before the undersigned Veterans Law Judge (VLJ) in Nashville, Tennessee (i.e., a Travel Board hearing). A transcript of the Board hearing is of record. Due to the Veteran's advanced age, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of: 1) service connection for bilateral hearing loss; 2) service connection for a hernia; 3) service connection for a back disability; 4) service connection for right upper extremity carpal tunnel syndrome; 5) service connection for left upper extremity carpal tunnel syndrome; 6) a TDIU; and 7) non-service-connected pension benefits are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran was exposed to asbestos and performed hard labor with little rest during service. 2. The Veteran was not exposed to mustard gas during service. 3. There was no injury or disease of the heart or chronic symptoms of a heart disability in service. 4. A heart disability did not manifest to a compensable degree within one year of service. 5. Symptoms of a heart disability have not been continuous since separation from service, and the Veteran's current heart disability with pacemaker is not causally or etiologically related to active service, to include any incident or event therein such as asbestos exposure. 6. There was no injury or disease of the vascular system or chronic symptoms of hypertension in service. 7. Hypertension did not manifest to a compensable degree within one year of service. 8. Symptoms of hypertension have not been continuous since separation from service, and the Veteran's current hypertension is not causally or etiologically related to active service, to include any incident or event therein such as asbestos exposure. CONCLUSIONS OF LAW 1. A heart disability with pacemaker was not incurred in active military service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. Hypertension was not incurred in active military service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and the representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In the March 2010 notice letter sent prior to the initial denial of the service connection claims, the RO apprised the Veteran of the information and evidence necessary to substantiate the claims for service connection, the information and evidence that he was to provide, and the information and evidence that VA would attempt to obtain on his behalf. In this regard, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits for the claimed disorders, and described the types of information and evidence that the Veteran needed to submit to substantiate the claims. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claims decided herein. The RO further informed the Veteran how VA determines the disability rating and effective date once service connection is established, which satisfied Dingess notice requirements. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied prior to the initial denial of the claims, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the Board notes that the record contains all available evidence pertinent to the claims. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of the responsibility to provide VA with any treatment records pertinent to the claims adjudicated herein, and the record contains sufficient evidence to make a decision on the claims. The complete service treatment records are included in the claims file, and available post-service treatment records identified as relevant to the Veteran's claims have been obtained or otherwise submitted. The Veteran requested treatment records directly from the VA hospital in Hines, Illinois, that were relevant to his claims for a heart disability and hypertension and submitted them to the RO for consideration. See February 2010 VA Form 21-4142 (wherein the Veteran notes treatment for the heart and "blood" and wrote that the records from VA Hines Illinois were attached); see also September 2009 letter from the VA hospital to the Veteran (stating that it was enclosing a copy of the information he requested). It is reasonable to conclude that the Veteran's request and submission of treatment records from the VA hospital covered all treatment records relevant to the claims adjudicated herein. There are no additional treatment records found in the Veteran's Virtual VA file. The Board notes that there is no duty to obtain records from the Social Security Administration (SSA) in this case. Although the Veteran indicated, on the March 2010 VA Form 21-526, that he was in receipt of Social Security disability benefits, the SSA Inquiry performed by VA in March 2010 showed that he is in receipt of Supplemental Medical Insurance benefits from the SSA, not disability benefits. Therefore, records from SSA are not relevant to the current appeal, and there is no need to obtain them before proceeding with appellate review. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (providing that when VA is put on notice of the existence of SSA records that have the reasonable possibility of substantiating a veteran's claim for benefits, it must seek to obtain those records before proceeding with the appeal). The Veteran has not been provided a VA medical examination or medical opinion in connection with the claims adjudicated herein; however, no medical examination or medical opinion is needed. As explained below, the weight of the evidence is against finding that the Veteran's heart disability with pacemaker or that hypertension had its onset during service, or that there was an in-service injury or disease of the heart of cardiovascular system, or that chronic symptoms manifested during service, that a cardiovascular disability manifested to a compensable degree within one year of service separation, or that continuous symptoms manifested since service separation. The Veteran has provided no competent evidence linking either the heart disability or hypertension, which manifested many years after service, to service, to include asbestos exposure or hard labor. The Veteran's lay assertion that a relationship between the disabilities and service exists is insufficient because he is not competent to attribute his current heart disability and/or hypertension to service and is not supported by the medical evidence of record. The record further does not establish exposure to mustard gas during service. For these reasons, the Board does not find that a medical examination or medical opinion is necessary. See Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). 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) requires that the VA employee who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the May 2013 Board hearing, the undersigned VLJ identified the issues on appeal, including specific theories of service connection for the issues (asbestos, mustard gas, chemicals, paint chipping, hard labor), elicited any problems that were not documented in the service treatment record, and elicited testimony as to when symptoms of disabilities began. The VLJ also posed several questions of the Veteran and his son during the course of the Board hearing to clarify the contentions and to ascertain whether there was additional evidence pertinent to the appeal that needed to be obtained. The VLJ advised the Veteran of the nature and proof required for chronic diseases (presumptive service connection), and explained the evidence needed (nexus opinions) to establish service connection for the claimed disabilities. The VLJ informed the Veteran that he could submit medical opinions linking his claimed disabilities to service. The Board held the record open for 60 days to allow the Veteran time to obtain and submit supportive medical opinion evidence. No evidence was submitted by the Veteran during this period. In consideration thereof, the Board finds that the duties under 38 C.F.R. § 3.103(c) (2) were satisfied. The Veteran has not made the RO or the Board aware of any notice defect or any additional evidence relevant to the appeal that needs to be obtained. Given the foregoing, the Board concludes that the Veteran has been provided with proper notice and all relevant facts have been properly and sufficiently developed in this appeal. No further notice or development is required. In view of the foregoing, the Board will proceed with appellate review. Service Connection Legal Criteria for a Heart Disability and Hypertension It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all of the evidence in this case. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The analysis below focuses on the most relevant evidence and on what this evidence shows, or fails to show, on the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122 (2000). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran is currently diagnosed with coronary disease and hypertension. Cardiovascular disease and hypertension are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service- connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as cardiovascular disease including hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service Connection Analysis for a Heart Disability and Hypertension The Veteran asserts that he has had hypertension and a heart disability since service. See March 2010 VA Form 21-526 (wherein the Veteran alleges that his disabilities began in November 1945). He also alleges that the disabilities are related to in-service asbestos exposure, mustard gas exposure, and/or hard labor with little rest while serving in the Navy. See May 2013 Board hearing transcript, pages 2-3, In this case, the Veteran is currently diagnosed with a heart disability and hypertension. The Veteran's October 1998 summary of VA hospital admission includes discharge diagnoses of a heart disability such as coronary atherosclerosis, intermediate coronary syndrome, and cardiac dysrhythmias, as well as a discharge diagnosis of benign hypertension. The Veteran has competently and credibly reported that he continues to suffer from a heart disability and hypertension. Because a current heart disability and current hypertension are established by the evidence, the existence of a current disability is not in dispute, and the element of current disability needed to establish service connection is satisfied. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the Veteran suffered an injury or disease of the heart or vascular system during service or that chronic symptoms of a heart disability or hypertension occurred during service, that a heart disability or hypertension manifested to a compensable degree in the first post-service year, and that the Veteran has experienced continuous symptoms of a heart disability and/or hypertension since service. In this regard, the Board notes that the Veteran wrote, on the March 2010 VA Form 21-526, that both his heart condition with pacemaker and high blood pressure began in November 1945 (i.e., during service). However, the statement is inconsistent with other, more contemporaneous and more probative evidence of record. The service treatment records, which are complete, are absent of any complaint, finding, or treatment for a heart disability or hypertension. The August 1946 service separation examination report shows a normal cardiovascular system and heart, and the Veteran's blood pressure was within normal limits (i.e., 134/70 and 138/74) at that time. See 38 C.F.R. § 4.104, Note (1) (explaining that hypertension must be confirmed by readings taken two or more times on at least three different days and defining hypertension as diastolic blood pressure predominantly 90 mm or greater or systolic blood pressure predominantly 160 mm or greater). When asked to comment on abnormalities not otherwise noted or sufficiently described above, the service medical examiner specifically wrote "None." Because this evidence was generated contemporaneous to service and is, therefore, likely to reflect accurately the Veteran's physical state during service, it is of great probative value. The Board has considered the hearing testimony of the Veteran and his son that the Veteran was not allowed to go to sick call and seek medical attention like a normal soldier would during service because of his race. In this regard, the Board finds the hearing testimony to be credible. However, at the August 1946 service separation examination, neither hypertension nor a heart disability was found and the Veteran articulated no complaints or symptoms indicative of either disability. The Board also notes that the Veteran filed an application for outpatient treatment in August 1948, two years after service separation. At that time, he only identified dental work due to lack of treatment while in service as the treatment required and made no mention of a heart disability or hypertension. Later, the Veteran filed a VA claim for disability compensation benefits in November 1962; however, he did not then allege that he had heart problems or hypertension related to service, to include with onset or symptoms during service. In fact, he made no mention of a heart disability or hypertension. If the Veteran had suffered from heart disability or hypertension or symptoms related thereto during service, as he has recently alleged in connection with the current claim, it is likely that he would have filed claims with VA for the disabilities when he filed other VA claims for VA treatment or disability compensation in August 1948 and November 1962. The fact that he did not file such claims at those times weighs against the credibility of the assertion that his heart problems and hypertension began during service and/or have continued since that time, as well as weighs against finding that either disability manifested to a compensable degree within the first post-service year. In addition, the Veteran's post-service treatment records show that the Veteran's heart disability and hypertension did not manifest until many years after service. For example, in October 1998, the Veteran told a treating medical provider that his past medical history was significant for hypertension and reported that hypertension had been diagnosed twelve (12) years before by his primary care physician in Kentucky. Thus, according to the Veteran's own statement made for treatment purposes, hypertension was not diagnosed until approximately 1986, four decades after service separation. Also, when seeking medical treatment for chest pain in October 1998, the Veteran reported a negative history for angina and stated that he had had chest pain on and off for three to four weeks. The Veteran made no mention of service. These statements made by the Veteran for treatment purposes are particularly probative because the Veteran had a strong incentive to report accurately his medical history when seeking treatment for chest pain, which was later attributed to a heart disability. The Board further notes that, when the Veteran had a laminectomy and was hospitalized from February 1962 to March 1962, the treating VA physician noted in the hospital interim summary that the Veteran's past medical history was "essentially negative." The 1962 hospital summary also reveals that the Veteran demonstrated a blood pressure within normal limits (i.e., 116/74) with no heart abnormalities demonstrated at that time. Because the Veteran was seeking medical treatment and undergoing surgery, it is likely that he would have reported having medical conditions such as a heart disability or hypertension or that the conditions would have otherwise been detected if they were present at the time. Although the Veteran reported at the Board hearing that a heart condition was detected when being treated for the back condition, the VA hospital summary contradicts the assertion. Because the VA hospital summary was generated contemporaneous to the Veteran's back surgery and hospitalization, the Board finds the hospital summary to be more credible than the Veteran's more recent assertion relating the onset of heart disability and hypertension symptoms to service, which was first made many years after service when the Veteran's memory is less reliable. This post-service medical evidence, which reflects an absence of any report or finding of a heart disability or hypertension when seeking medical treatment in 1962 and includes the Veteran's own report that he had first been diagnosed with hypertension in 1986 and had recently experienced the onset of chest pain when seeking medical treatment in 1998, provides further evidence against the more recent assertion that his heart disability and hypertension, to include chronic symptoms related thereto, began during active service. This evidence also weighs against finding that a heart disability or hypertension manifested to a compensable degree in the first post-service year, or that there have been continuous symptoms of a heart disability or hypertension since service separation. The Veteran has further provided inconsistent statements regarding the onset of his heart problems and hypertension. For example, the Veteran stated on the March 2010 VA Form 21-526 that the heart disability and hypertension began in November 1945 (i.e., during service). However, at the Board hearing, he reported that he began to have heart problems in the late 1940s, which relates the onset of the disability to a time after service separation. See Board hearing transcript, pages 16-18. Also, when seeking medical treatment in October 1998, the Veteran told a treating medical provider that he had been diagnosed with hypertension twelve years earlier, denied having a history of angina, and reported that he had experienced chest pain on and off for three to four weeks. It is also specifically noted that in October 1998 the Veteran reported "no previous [history]." Thus, the Veteran's statements to medical providers in 1998 relate the onset of heart disability and hypertension to a time many years after service separation. Due to the inconsistent accounts, the Board does not find the Veteran to be a reliable historian when now relating the onset of symptoms of a heart disability and hypertension to his time in service. The Board finds the 1998 statements made to medical providers to be more probative because they were made for treatment purposes, so were more likely to be accurate. The Board next finds that the weight of the evidence is against finding that the Veteran's heart disability and hypertension, both of which first manifested many years after service, are causally or etiologically related to service. In this regard, the Board has also considered the Veteran's assertion that the current heart disability and hypertension are related to in-service asbestos exposure. There is no specific statutory or regulatory guidance with regard to claims for service connection for asbestos-related diseases. However, in 1988 VA issued a circular on asbestos-related diseases which provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans Administration, DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular were later included in the VA Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (Oct. 3, 1997) (M21-1). Subsequently, an opinion by the VA General Counsel discussed the development of asbestos claims. VAOPGCPREC 4-2000. The Board notes that the aforementioned provisions of M21-1 were rescinded and reissued as amended in a manual rewrite (MR) in 2005. See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 29, entitled "Developing Claims for Service Connection for Asbestos-Related Diseases," and Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9, entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." The latency period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. The exposure may have been direct or indirect, and the extent or duration of exposure is not a factor. M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 29a. The manual provisions acknowledge that inhalation of asbestos fibers and/or particles can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx, and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. As to occupational exposure, exposure to asbestos has been shown in manufacturing and servicing of friction products such as clutch facings and brake linings, and other occupations. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1MR, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9a-f. The applicable section of Manual M21-1 also notes that some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, military equipment, etc. High exposure to asbestos and a high prevalence of disease have been noted in insulation and shipyard workers, and this is significant considering that, during World War II, U.S. Navy veterans were exposed to chrysotile, amosite, and crocidolite that were used extensively in military ship construction. Furthermore, it was revealed that many of these shipyard workers had only recently come to medical attention because the latent period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. Also of significance is that the exposure to asbestos may be brief (as little as a month or two) or indirect (bystander disease). Department of Veterans Affairs, Veteran's Benefits Administration, Manual M21-1, Part 6, Chapter 7, Subchapter IV, § 7.21(b). The manual further provides that VA must determine whether military records demonstrate evidence of asbestos exposure in service, and whether there is pre-service and/or post- service evidence of occupational or other asbestos exposure; and then make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the Veteran. M21-1MR, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9h. In short, with respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post- service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1, Part VI, 7.21; DVB Circular 2-88-8, Asbestos-Related Diseases (May 11, 1988). In this case, the service records do not show asbestos exposure during service, and the Veteran and his son expressed uncertainty at the May 2013 Board hearing regarding the type of chemicals to which the Veteran may have been exposed while serving in the Navy. See, e.g., Board hearing transcript, page 7. However, the Veteran competently and credibly reported that he routinely stripped the bows on the naval ships as part of his military duties; therefore, because the Veteran's military duties included maintenance of the naval ship, the Board finds that exposure to asbestos is consistent with the conditions of the Veteran's service. The Veteran's heart disability and hypertension, however, are not conditions shown to be associated with asbestos exposure. The manual provisions acknowledge that inhalation of asbestos fibers and/or particles can result in certain disabilities; however, neither a heart disability nor hypertension is among the recognized disorders. The Veteran has not provided competent evidence that links the heart disability and/or hypertension to service, to include asbestos exposure during service. The treatment records do not indicate that a link between asbestos exposure and service exists. The Veteran, as a lay person, is not competent to attribute the currently diagnosed heart disability and hypertension to exposure to asbestos during service; therefore, his opinion is of no probative value. Regarding the assertion that the Veteran's heart disability and hypertension are related to in-service mustard gas exposure, VA requires that claims for service connection based upon mustard gas exposure be processed according to VA regulations set out in VA Manual, M21-1MR. According to M21-1MR, IV.ii.1.F.22.b, in attempting to verify claimed mustard gas exposure, evidence of full-body exposure to mustard gas or Lewisite should be requested only if the service connection claim is for a disability listed under 38 C.F.R. § 3.316(a), or if the veteran submits medical or scientific evidence showing a causal relationship between a disease not listed in 38 C.F.R. § 3.316(a) and exposure. In this case, the Veteran is diagnosed with a heart disability and hypertension, which are not disabilities listed under 38 C.F.R. § 3.316(a) as being associated with mustard gas exposure. Also, after the RO requested confirmation of the Veteran's exposure to mustard gas in March 2010, the response was negative. The Veteran testified that he was uncertain of what chemicals to which he may have been exposed during service, as stated above. For these reasons, the Board finds that the Veteran was not exposed to mustard gas during service. See Bardwell, 24 Vet. App. at 40 (holding that a layperson's assertions indicating exposure to gases or chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service). The Board further notes that the Veteran asserted at the Board hearing that the heart disability and hypertension are the result of hard labor with little rest during active service. There is no indication in the record that the Veteran's account of having to perform hard labor with little rest during active service is not credible; however, as stated above, the service treatment records are absent of any complaints, findings, or treatment for cardiovascular problems, and the first evidence of cardiovascular disability is many years after service separation. The Veteran has not presented competent and credible evidence of a link between the heart disability and hypertension and active service, to include as due to hard labor with little rest during service. The Veteran, as a lay person, is not competent to attribute the currently diagnosed heart disability and hypertension to hard labor during service; therefore, his opinion is of no probative value. Lastly, at the Board hearing, the Veteran asserted that the heart disability and hypertension were caused by lead poisoning due to being exposed to lead paint while stripping the naval ships and/or other toxic chemicals while cleaning debris resulting from target practice during active service. However, as stated above, the Veteran has not presented competent and credible evidence of a link between the heart disability and hypertension and active service, to include as due to lead poisoning or exposure or to exposure to toxic chemicals. The Veteran, as a lay person, is not competent to attribute the currently diagnosed heart disability and hypertension to exposure to lead paint and/or other toxic chemicals during service; therefore, his opinion is of no probative value. Although the Veteran has repeatedly asserted that his heart disability and hypertension are causally related to service, the Veteran is a lay person and does not have the requisite medical expertise to be able to render a competent medical opinion regarding the cause of the heart disability or hypertension, both of which are shown to have first manifested many years after service. The etiology of the Veteran's heart disability is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran, and the Veteran's heart disability is a disorder diagnosed primarily on clinical findings and physiological testing. An opinion regarding its etiology or cause is beyond the competence of the Veteran. Although the VLJ advised the Veteran at the Board hearing that a medical opinion linking the disability to service may help to substantiate the claim, no such medical opinion has been received, and there is no competent evidence of record that a linkage between the heart disability and active service may exist. The Veteran has further provided inconsistent statements regarding the onset of a heart disability, as explained above. In consideration thereof, the Veteran's statement that the symptoms of heart disability began in service and continued thereafter is not credible evidence and, consequently, is of no probative value. Regarding the Veteran's diagnosis of hypertension, the Board notes that the Veteran is competent to report his blood pressure readings on different days and, perhaps, could provide sufficient information to establish a diagnosis of hypertension and the onset of symptoms related thereto. However, in this case, the Veteran has not provided evidence of blood pressure readings reflective of hypertension during service or during the first-post service year. In fact, the service medical evidence and post-service medical evidence shows blood pressure readings within normal limits at service separation and in 1962, which provides evidence against finding hypertension during service or in the first post-service year. The Veteran also told treating VA medical providers in 1998 that hypertension was first diagnosed many years after service and made no mention of service. The Veteran has further provided inconsistent statements regarding the onset of hypertensive symptoms, as explained above. In consideration thereof, the Veteran's statement that the hypertensive symptoms began in service and continued thereafter is not credible evidence and, consequently, is of no probative value. In summary, the credible evidence of record shows no cardiovascular injury or disease during service, and that the Veteran's heart disability and hypertension, to include chronic symptoms related thereto, first manifested many years after service. The Veteran was not exposed to mustard gas during service. There is no competent medical opinion evidence linking either disability to active service, to include asbestos exposure or hard labor. For these reasons, the Board finds that the preponderance of the evidence is against the claims and service connection for a heart disability or hypertension is not warranted on either a direct basis or on a presumptive basis as a chronic disease. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a heart disability with pacemaker is denied. Service connection for hypertension is denied. REMAND After review of the record, the Board finds that additional development is needed before proceeding with appellate review for the issues of service connection for bilateral hearing loss, service connection for a hernia, service connection for a back disability, service connection for carpal tunnel syndrome, a TDIU, and pension benefits. Service Connection for Bilateral Hearing Loss At the Board hearing, the Veteran competently and credibly reported that he was exposed to the loud noise of heavy equipment and gunfire during active service and had noticed that his hearing had gotten "bad" during the past four to five years. See Board hearing transcript, pages 14-16. The Veteran has not yet been provided with a VA medical examination or a medical opinion addressing likelihood of whether he currently suffers from a hearing loss disability due to acoustic trauma resulting from in-service noise exposure; therefore, a remand for a VA medical examination with a medical opinion is warranted. Service Connection for a Hernia At the Board hearing, the Veteran testified that he performed hard labor with little rest while serving in the Navy. The Veteran believes that such labor may have caused disability, to include his claimed hernia. On the March 2010 VA Form 21-526, the Veteran wrote that he had undergone a hernia repair and indicated that he had been treated for a hernia at the VA hospital in Hines, Illinois; however, no records from the facility pertaining to treatment for a hernia have been obtained or submitted, and the current record contains no medical evidence of diagnosis or treatment of a hernia. For these reasons, the Board finds that a remand to obtain VA treatment records from the facility for the period from August 1946 to the present. See Bell v. Derwinski, 2 Vet. App. 611, 612-13 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Service Connection for a Back Disability At the Board hearing, the Veteran competently and credibly reported that he experienced back pain during service. He asserts that the back pain during service later developed into his current back disability. The Veteran has not yet been provided with a VA medical examination or medical opinion on the likelihood that he suffers from a back disability due to back pain during service; therefore, a remand for a VA medical examination with a medical opinion is warranted. Service Connection for Bilateral Upper Extremity Carpal Tunnel Syndrome At the Board hearing, the Veteran competently and credibly reported that he performed repetitious work with his hands during service (i.e., stripping the bows of the ships). He asserts that such work caused him to develop tingling in his hands, which he believes is carpal tunnel syndrome. The Veteran has not yet been provided with a VA medical examination or medical opinion on the likelihood that he suffers from carpal tunnel syndrome in the bilateral upper extremities due to labor performed during service; therefore, a remand for a VA medical examination with a medical opinion is warranted. TDIU The Board finds that the Veteran's TDIU claim is inextricably intertwined with the service connection claims being remanded for reasons above. The Board has arrived at this conclusion because the outcome of the Veteran's service connection claims potentially impacts the claim for a TDIU. The Veteran is not currently service connected for any disability; therefore, final adjudication of the TDIU claim must be deferred until the ordered development on the remanded service connection claims is accomplished and the claims are readjudicated. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Non-service-connected Pension Benefits Subject to certain income and estate limitations, non- service-connected pension is payable to any veteran who served at least 90 days during a period of war who is permanently and totally disabled from disability that is not the result of his own willful misconduct. 38 U.S.C.A. §§ 1502, 1521 (West 2002); 38 C.F.R. §§ 3.2(f), 3.23, 3.3 (2012). A veteran is considered to be permanently and totally disabled if he is suffering from a disability or combination of disabilities that are sufficient to prevent the average person from following a substantially gainful occupation, that is reasonably certain to continue throughout his life, or if he is in fact unemployable as a result of disability or disabilities that are reasonably certain to continue throughout his life. 38 U.S.C.A. § 1502; Vargas-Gonzalez v. West, 12 Vet. App. 321 (1999). In this case, the Veteran satisfies the requirement of serving during a period of war, the World War II era. Moreover, there is no current evidence that his income or assets render him ineligible for pension benefits. Accordingly, the issue of entitlement to VA pension turns on whether he is permanently and totally disabled as a result of nonservice-connected disabilities that were not the result of his own willful misconduct. In order to properly to make this determination, the Board finds that a VA medical examination is needed to assist in determining the extent and severity of all of the non-service-connected disabilities present, and whether those disabilities are permanent in nature. Accordingly, the issues of: service connection for bilateral hearing loss; service connection for a hernia; service connection for a back disability; service connection for right upper extremity carpal tunnel syndrome; service connection for left upper extremity carpal tunnel syndrome; and a TDIU are REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Obtain the Veteran's treatment records from the Edward Hines Jr. VA hospital in Hines, Illinois, from August 1946 to the present and associate them with the record. If no records are available, make specific note of that fact in the record and follow the procedures outlined in 38 C.F.R. §3.159(e) regarding notification of the inability to obtain records. 2. Schedule the Veteran for appropriate medical examination for the claimed hearing loss disability. All relevant documents should be made available to and reviewed by the examiner in rendering the opinion. In the examination report, the examiner should confirm that the record was reviewed. Based on review of the appropriate records, the examiner should offer an opinion as to whether it is as likely as not (i.e., to at least a 50 percent degree of probability) that any current hearing loss is causally or etiologically related to service, to include any acoustic trauma sustained therein. The examiner should explain the answer. For the purpose of providing the medical opinion, the examiner should accept the Veteran's report of in-service noise exposure as fact. The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. If the examiner cannot answer any question posed without resorting to speculation, the examiner should so state, and explain why that is so. 3. Schedule the Veteran for appropriate medical examination for the claimed back disability. All relevant documents should be made available to and reviewed by the examiner in rendering the opinion. In the examination report, the examiner should confirm that the record was reviewed. Based on review of the appropriate records, the examiner should state, for each diagnosis, an opinion as to whether it is as likely as not (i.e., to at least a 50 percent degree of probability) that any current back disorder had its onset during service or was otherwise causally or etiologically related to service, to include any symptomatology, event, or incident therein. The examiner should explain the answer. For the purpose of providing the medical opinion, the examiner should accept the Veteran's report of in-service back pain as fact. The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. If the examiner cannot answer any question posed without resorting to speculation, the examiner should so state, and explain why that is so. 4. Schedule the Veteran for appropriate medical examination for the claimed carpal tunnel syndrome of the bilateral upper extremities. All relevant documents should be made available to and reviewed by the examiner in rendering the opinion. In the examination report, the examiner should confirm that the record was reviewed. Based on review of the appropriate records, the examiner should offer an opinion as to whether it is as likely as not (i.e., to at least a 50 percent degree of probability) that any current disorder involving the bilateral upper extremities was causally or etiologically related to service, to include any symptomatology, event, or incident therein. The examiner should explain the answer. For the purpose of providing the medical opinion, the examiner should accept the Veteran's report of performing repetitious work with his hands during service as fact. The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. If the examiner cannot answer any question posed without resorting to speculation, the examiner should so state, and explain why that is so. 5. Schedule a VA general medical examination for pension purposes to determine the extent and severity of all of the non-service-connected disabilities present, and whether those disabilities are permanent in nature. The relevant documents from the record should be provided to the VA examiner and should be reviewed by the VA examiner in connection with the examination. In the examination report, the examiner should confirm review of the record. An interview of the Veteran regarding the relevant medical and work history, a physical examination, and all tests and studies required to respond to the following questions should be performed. Based on review of the appropriate records, the examiner should identify the level of functional impairment associated with all such disabilities shown, and indicate whether they are permanent in nature. If the disabilities are permanent in nature, the examiner should state whether there is sufficient impairment of mind or body to render it impossible for the average person to follow a substantially gainful occupation, and/or render the Veteran incapable of substantially gainful employment. The examiner should set forth all examination findings, along with the complete rationale for the conclusions reached. 6. When the development above has been completed, the remanded issues should be readjudicated. If any benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs