Citation Nr: 1400515 Decision Date: 01/07/14 Archive Date: 01/23/14 DOCKET NO. 99-07 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at law ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The Veteran served on active duty from December 1941 to April 1942, and from March 1945 to May 1946. He was a prisoner of war (POW) from April 9 to April 13, 1942. The Veteran died in August 1978. The appellant in this case is the Veteran's widow. This matter originally came to the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. In February 2001, the Board remanded the matter to the RO for additional evidentiary development and due process considerations, to include affording the appellant the opportunity to submit or identify additional evidence and complying with the newly enacted Veterans Claims Assistance Act of 2000. Following the completion of that action, in a November 2002 decision, the Board denied service connection for the cause of the Veteran's death, finding that the cause of his death, including metastatic liver cancer with pneumothorax, was not linked to his active service or any incident therein. In March 2003, the Board denied the appellant's motion for reconsideration of its November 2002 decision. The appellant appealed the Board's November 2002 decision to the United States Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, in June 2004, the appellant's attorney and a representative of VA's Office of General Counsel filed a Joint Motion for Remand, arguing that the Board had failed to address the appellant's contentions to the effect that the Veteran "may have had malaria in service in 1946; that [he] had chronic malaria in 1978 which may have aggravated his pneumonia; and that pneumonia was one cause of the veteran's death." See Joint Motion at page 4 (citations omitted). In a June 2004 order, the Court granted the motion, vacated the Board's November 2002 decision, and remanded the matter for readjudication. In compliance with the Court's order, in October 2004, the Board remanded the matter to the RO for additional evidentiary development, to include affording the appellant another opportunity to submit or identify additional evidence and obtaining a medical opinion addressing her contentions regarding the cause of the Veteran's death. Following the completion of that action, in a March 2005 decision, the Board again denied service connection for the cause of the Veteran's death, finding that the medical opinion obtained established that neither the Veteran's fatal metastatic cancer nor his pneumonia was related to service, to include an apparent episode of in-service malaria with a claimed recurrence in 1978. The appellant appealed the Board's March 2005 decision to the Court. In a June 2007 memorandum decision, the Court vacated the Board's March 2005 decision and remanded the matter for readjudication. The Court held that although the medical opinion obtained by VA was thorough in explaining why malaria had not caused the Veteran's pneumonia and why malaria had not been present at the time of his death, it did not address the question of whether a possible malaria recurrence in 1978, four months prior to the Veteran's death, could have aggravated the Veteran's pneumonia. In compliance with the Court's order, in February 2008, the Board again remanded the matter to the RO for additional evidentiary development, to include affording the appellant another opportunity to submit or identify additional evidence and obtaining a supplemental medical opinion. Pursuant to the Board's remand instructions, the RO obtained a medical opinion in April 2008 in which a VA physician explained that it was less likely than not that the Veteran's pneumonia had been aggravated by malaria. In November 2008, the Board again remanded the matter to the RO for the purpose of complying with the request of the appellant's attorney for a copy of the April 2008 medical opinion. Following the completion of that action, in a March 2009 decision, the Board again denied service connection for the cause of the Veteran's death, finding that the most probative evidence established that neither the Veteran's fatal metastatic cancer nor his pneumonia was related to his active service, to include an apparent episode of in-service malaria with a claimed recurrence in 1978, nor had his pneumonia been caused or aggravated by malaria. The appellant appealed the Board's March 2009 decision to the Court. While the matter was pending before the Court, in October 2009, the appellant's attorney and a representative of VA's Office of General Counsel filed another Joint Motion for Remand, stating that a remand was necessary because the RO had failed to consider written arguments the appellant's counsel had submitted prior to returning the matter to the Board. In a November 2009 order, the Court granted the motion, vacated the Board's March 2009 decision, and remanded the matter for readjudication. In compliance with the Court's order, in August 2010, the Board remanded the matter to the RO for readjudication with consideration of the written arguments of the appellant's attorney. While the matter was in remand status, in November 2010, the RO obtained an additional medical opinion which again indicated that it was less likely than not that the Veteran's episode of pneumonia in 1978 had been aggravated by malaria. In July 2011, again at the request of the appellant's attorney, the Board remanded the matter for additional evidentiary development, to include obtaining another clarifying medical opinion. As set forth in more detail below, in April 2012, a VA physician again explained that the pneumonia which caused the Veteran's death was not causally related to or aggravated by malaria. As set forth in more detail below, although the appellant's attorney has again requested a remand of this matter, the Board finds that VA has substantially complied with all remand instructions and that there is no basis to delay this longstanding matter any further by remanding it for the seventh time. D'Aries v. Peake, 22 Vet. App. 97, 106 (2008). FINDINGS OF FACT 1. The Veteran died in August 1978; his death certificate does not include a cause of death but terminal hospital records and an autopsy report indicate that the cause of his death was metastatic carcinoma involving the liver, lungs, and lymph nodes with pneumonia. 2. At the time of the Veteran's death, service connection had not been established for any disability. 3. A service-connected disability did not cause or contribute materially or substantially to the Veteran's death, nor was the cause of his death, metastatic carcinoma involving the liver, lungs, and lymph nodes with pneumonia, otherwise causally related to his active service or any incident therein. Rather, the most probative evidence establishes that neither the Veteran's fatal metastatic carcinoma nor his pneumonia was causally related to his active service or any incident therein, including an episode of malaria or a claimed recurrence of malaria in 1978, nor was either condition causally related to or aggravated by malaria. CONCLUSION OF LAW A service-connected disability did not cause or contribute substantially or materially to cause the Veteran's death. 38 U.S.C.A. §§ 1310, 5107 (West 2002); 38 C.F.R. §§ 3.307, 3.309, 3.310, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. In March 2001 and May 2008 letters, VA notified the appellant of the information and evidence needed to substantiate and complete her claim, and of what part of that evidence she was to provide and what part VA would attempt to obtain for her. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2013). The May 2008 letter also substantially satisfied the additional notification requirements imposed by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) and Hupp v. Nicholson, 21 Vet. App. 342 (2007). Moreover, since the issuance of the March 2001 and May 2008 letters, the RO has reconsidered the appellant's claim on multiple occasions, most recently in the June 2013 Supplemental Statement of the Case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). In addition to these notification letters, the Board observes that the issue on appeal has been the subject of six prior Board remands, three prior Board decisions, and three appeals to the Court, nearly all of which included clear and detailed discussions of the information and evidence needed to substantiate the claim and/or VA's compliance with 38 U.S.C.A. § 5103. The Board also observes that since 2003, the appellant has been represented by the same attorney, one with nearly two decades of experience in Veterans' law. Under these circumstances, it is clear that any defects in VA's VCAA notification actions have been nonprejudical given the appellant's actual and/or constructive knowledge of the information and evidence necessary to substantiate her claim. See e.g. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds sub nom. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (noting that the purpose of the VCAA notice requirement is not frustrated if, for example, the claimant has actual knowledge of what is needed or a reasonable person could be expected to understand what is needed); see also Overton v. Nicholson, 20 Vet. App. 427, 438 (2006) (noting that representation is a factor that must be considered when determining whether that appellant has been prejudiced by a VCAA notice error). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The Veteran's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain. Neither the appellant nor her attorney has argued otherwise or specifically identified any relevant, outstanding evidence despite being given multiple opportunities to do so. 38 U.S.C.A. § 5103A(c) (West 2002); 38 C.F.R. § 3.159(c)(2), (3) (2013). The Board also observes that VA has now obtained five medical opinions in connection with this claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013); see also Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008) (holding that in the context of a DIC claim, VA has an obligation to assist a claimant in obtaining evidence necessary to substantiate a claim, including a medical opinion, unless there is no reasonable possibility that such assistance would aid in substantiating the claim). The Board finds that the opinions VA has obtained, when read collectively, provide a sufficient basis upon which to decide the claim. The opinions were provided by qualified medical professionals, including a VA physician specializing in internal medicine and pulmonary diseases, and were predicated on a full reading of all available records. The medical professionals also provided detailed rationales for the opinions rendered, including reference to the appellant's contentions and the applicable medical literature. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board has considered the contentions of the appellant's attorney to the effect that the most recent medical opinions obtained are incorrect and/or do not contain a "clear conclusion." He claims that the physician's "medical conclusion is that Malaria is not infectious in nature" which is incorrect because "malaria is a serious infectious disease." See July 2013 written arguments. The lack of medical qualifications of the appellant's attorney notwithstanding, his arguments represent either a mischaracterization or misunderstanding of the VA physician's conclusions. Rather, as the VA physician has clearly explained on multiple occasions, the medical record in this case indicates that the type of pneumonia which the Veteran exhibited was caused by a viral or bacterial infection, as it was characterized by tissue inflammation in the lungs. Thus, even if malaria had been present concurrently, the type of pneumonia the Veteran exhibited was not caused or aggravated by malaria, as the type of pneumonia which resulted from a complication of malaria is not infectious in nature; rather, it is characterized by capillary leakage, which the appellant did not exhibit. Most recently, the appellant's attorney advanced argument the effect that the medical opinions obtained by VA are inadequate because they did not consider whether having malaria "predisposed the veteran to be in a weaker physical state such that he was less capable of resisting the effects of the pneumonia that caused his death." See October 2013 written arguments. As set forth above, however, the medical opinions obtained have been clear that malaria was not present at the time of the Veteran's death and that the Veteran had not been ill from malaria so as to develop pneumonia in 1978. Finally, the record is clear that even if it is presumed for the sake of argument that the appellant suffered a malaria recurrence in 1978, the pneumonia which caused his death was wholly unrelated, given the type of pneumonia exhibited by the appellant at death. Rather, the Veteran's fatal pneumonia was a clear complication of malignancy. In summary, as set forth in more detail below, the Board finds that the medical opinions in this case are both clear and adequate and conclude consistently and unequivocally that the neither the Veteran's fatal metastatic carcinoma nor his pneumonia was causally related to his active service or any incident therein, including an apparent episode of malaria or a claimed recurrence of malaria in 1978, nor was either condition causally related to or aggravated by malaria, nor did malaria predispose the Veteran to be in a weaker physical state such that he was less capable of resisting the effects of the pneumonia which caused his death. The Board concludes that the arguments of the appellant's attorney do not provide a basis for seventh remand in order to obtain a sixth medical opinion in this case. Although the appellant's attorney disagrees with the opinions obtained and/or finds them unclear, VA's "duty to assist is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support the claim." See Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992). The appellant and her attorney were free to procure an alternative or clarifying medical opinion and submit it to VA but chose not to do so, despite being given multiple opportunities to submit additional evidence. See 38 U.S.C.A. § 5107(a) (it is a claimant's responsibility to support a claim for VA benefits). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issue now being decided. Background In pertinent part, the service treatment records show that the Veteran was treated in March 1942 for a fever of unknown origins. In March 1946, while undergoing treatment for injuries incurred in a motor vehicle accident, the Veteran gave a history of having had malaria in 1942. It is not clear if the reported malaria occurred during a period of active duty. In pertinent part, the post-service record on appeal includes medical records showing that in August 1978, the appellant presented to Veterans Memorial Medical Center with complaints of an enlarged abdomen and a productive cough. On admission, it was noted that he had had a slight to moderate fever, weight loss, enlargement of his abdomen, changes in his bowels, and a productive cough three weeks to two months prior to his admission. The final hospitalization summary notes diagnoses of cirrhosis with hepatic malignancy and pneumonia, right. According to his certificate of death, the Veteran died in August 1978 at the age of 60, while hospitalized at the Veterans Memorial Medical Center. The certificate of death does not list a cause of death. Terminal hospital records and an autopsy report, however, indicate that the Veteran died from metastatic carcinoma of the liver, involving the lungs and lymph nodes. Records also list pneumonia and pneumothorax. At the time of the Veteran's death, service connection had not been established for any disability. In October 1979, the appellant submitted an application for Dependency and Indemnity Compensation, seeking service connection for the cause of the Veteran's death. In support of her claim, the appellant submitted an affidavit from R.G, purportedly signed in February 1946. R.G. indicated that the Veteran had escaped from the Bataan Death March in April 1942, after which he had stayed at her home and had been sick with malaria for about one year. An affidavit from Dr. S. J. L., also purportedly signed in February 1946, attests that he had treated the Veteran's malaria for one year. Also in support of her claim, the appellant submitted a February 1980 medical certificate from J.Y.C., M.D., who indicated that he had treated the Veteran on April 15, 1978, for various complaints, including a productive cough, fever, a "chilly sensation," sweating, chest and back pain, anorexia, and general body weakness. Dr. C.'s clinical diagnoses were chronic malaria and pneumonia. He indicated that "this malaria may cause serious infection with localization of the causative agent (pneumonic type)." In November 2004, a VA physician reviewed the Veteran's claims file for the purposes of providing a medical opinion in connection with the appellant's claim. The VA physician observed that in a February 1980 note, Dr. C. appeared to attribute the appellant's April 1978 episode of pneumonia to chronic malaria. He noted, however, that there was no mention of any laboratory testing which would affirmatively identify malaria. The physician further noted that when the appellant had died four months thereafter, an autopsy had revealed that the cause of his death was malignancy of the liver, lungs, and lymph nodes with pneumonia. The VA physician opined that the Veteran's fatal pneumonia was a complication of malignancy rather than due to malaria. He explained that patients with lung cancer developed pneumonia as a result of obstruction of the lung airways. Indeed, he noted that this was the most common exit of patients with lung malignancy. The physician further noted that it was possible that the pneumonia with which the appellant had been diagnosed four months prior to his death had been due to the lung malignancy and not chronic malaria as his physician had indicated. In that regard, the VA physician noted that there had been neither proof nor mention of any laboratory testing done to support the diagnosis of malaria. In addition, he noted that there had been no finding whatsoever of liver or spleen enlargement in the autopsy report, which is would be expected in a patient with chronic malaria. This was indicative of the fact that the appellant had not had chronic malaria at the time of his death. The VA physician noted that even assuming that the Veteran had had malaria four months before his death, there had been no evidence that he had had malaria at the time of his death. The examiner additionally explained that there are four types of malaria. Among the four types, the most serious (falciparum malaria) could involve the lungs in the form of Adult Respiratory Distress Syndrome (ARDS) or pulmonary edema but not pneumonia. In severe cases of ARDS when the brain can become involved (cerebral malaria), the patient might develop pneumonia indirectly as a result of aspiration when the patient develops a seizure or becomes comatose. In both ARDS and cerebral malaria, however, the patient becomes severely ill and incapacitated as a result of the severe malarial infection and would require prolonged hospitalization, usually ending up fatally. The VA physician explained that based on the record, the Veteran had not been severely ill from malaria so as to develop pneumonia as there was no indication in the record that the Veteran had been hospitalized for it. The VA physician explained that hospitalization for ARDS or cerebral malaria would be hard to miss and would have been included in the Veteran's medical history. Based on his review of the record and the applicable medical literature, the VA physician concluded that the clinical course of the Veteran's illness was in accord with the evidence on the autopsy report that the Veteran had died of malignancy from liver, lungs and lymph nodes with pneumonia. The physician further opined that the pneumonia no doubt contributed substantially to the Veteran's death but that it was not likely that the malaria had caused the pneumonia. In its June 2007 memorandum opinion, the Court described the November 2004 VA medical opinion as "thorough" in explaining both why malaria had not caused the Veteran's pneumonia and why malaria had not been present at the time of the Veteran's death. Because the physician did not address the question as to whether the Veteran's malaria, which he assumed existed four months prior to death, could have aggravated the Veteran's pneumonia, a remand was necessary. Pursuant to the Court's instructions, the RO requested a VA medical opinion addressing the question of whether it is at least as likely as not that the Veteran's malaria aggravated his pneumonia. In an April 2008 medical opinion, a VA physician indicated that after reviewing the record, it was his conclusion that it was less likely than not that the Veteran's malaria had aggravated his pneumonia. The physician explained that the findings in active malaria represented by the erythrocytic stage generally included red blood cell destruction, pancytopenia, increased malarial antibodies, and splenomegaly. He noted that upon admission to the August 1978 period of hospitalization, the Veteran was noted to have an anicteric sclerae, which eliminated the presence of gross jaundice, and a CBC finding of leukocytosis and normal hemoglobin levels which signified the absence of a chronic hemolytic process. The physician further noted that although the Veteran exhibited a fever during the course of hospitalization, the characteristic episodic fever cycle in malaria was absent. In addition, he observed that excess hemoglobin in the urine or sequestration in the form of splenomegaly had also not been detected. The VA physician further noted that post-mortem findings did not include any malaria related pathology with the ascites and hydrothorax determined to be a result of his liver cirrhosis. In the absence of anemia, signs of red blood cell hemolysis, and splenomegaly, the VA physician indicated that the Veteran's pneumonia was less likely as not aggravated by malaria. In February 2009 written arguments, the appellant's attorney argued that although the VA physician had concluded that the Veteran's "service-connected" malaria had not aggravated his pneumonia at the time of his death, he had failed "to address whether, assuming malaria had been present four months before death, that the pneumonia had been aggravated at that time." In a November 2010 opinion, the VA physician provided an addendum to his April 2008 opinion. He explained that even assuming that malaria had been present four months prior to the Veteran's death, it was less likely than not that it had aggravated his pneumonia at that time. The physician explained that the etiology of pneumonia is commonly due to a viral or bacterial organism which can resolve with or without antibiotic treatment. The examiner noted that, if the Veteran's malaria had been active four months before death, he would have presented with symptoms of tachycardia and tachypnea along with bruising and jaundice; these can mimic symptoms of active pneumonia which includes fever and productive cough, although productive cough is necessary for making a diagnosis. If indeed the Veteran had had an active malaria infection four months before death, the parasitized and non parasitized red blood cells could have adhered to the small vessels and produced small infarcts, capillary leakage or organ dysfunction that could have adhered to the small vessels and produced small infarcts, capillary leakage or organ dysfunction that could have lead to ARDS of the lung if complications were severe. He explained that this pneumonia picture, however, is different from the etiology and presentation of the type of pneumonia where a bacterial or viral infection is present and cough, fever, and shortness of breath is caused by tissue inflammation rather than capillary leakage present in ARDS. Since the lung complication of malaria is not infectious in nature, the pneumonia exhibited by the Veteran was less likely as not aggravated by the malaria, assuming it had been present at that time. In March 2011, the appellant's attorney argued that the November 2010 medical opinion was inadequate for rating purposes because the name and credentials of the medical professional who had authored it were not provided. He further argued that the opinion's rationale was flawed because the author stated that the Veteran's "malaria could not have aggravated the pneumonia because it was not infectious in nature." The appellant's attorney indicated that "[i]t is unclear how an infection is not infectious in nature." On these grounds, the appellant's attorney requested a new medical opinion. In April 2011, the RO pointed out that the author of both the April 2008 VA medical opinion, as well as the November 2010 addendum, was a VA physician who specialized in internal and pulmonary medicine. In April 2012, that same VA physician provided a second addendum. He again explained that the lung involvement in pneumonia was infectious in nature, which means that white blood cells or inflammatory cells lead into the alveolar space as a reaction of the body against a foreign agent. In the case of pneumonia, the foreign body is a bacteria or virus. On the other hand, he again explained that the lung complication due to severe malaria is caused by the development of ARDS or drowning of the lung alveolar spaces with noninfectious fluid coming from the fragile blood vessels; in the case of severe malaria where capillary leakage is present; white blood cells are not involved and therefore it is not infectious in nature. He explained that the appellant's pneumonia had been due to an infection, i.e. a virus or bacteria, not to malaria. Applicable Law Cause of death To establish service connection for the cause of the Veteran's death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312 (2013). A service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b) (2013). A contributory cause of death is inherently one not related to the principal cause. In determining whether a service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it causally shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c) (2013). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3) (2013). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4) (2013). Service connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2013). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2013). Service connection for certain chronic diseases, including malignant tumors, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2013). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a) (2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis As set forth above, the Veteran's certificate of death shows that he died in August 1978 at the age of 60. Although the document does not include a cause of death, terminal hospital records and an autopsy report indicate that he died from metastatic carcinoma involving the liver, lungs and lymph nodes with pneumonia. As a preliminary matter, the Board notes that during the Veteran's lifetime, service connection had not been established for any disability. Furthermore, the record does not show, nor does the appellant contend, that the cancer or pneumonia which were noted to have caused or contributed to the Veteran's death had their inception during his active service, were manifest to a compensable degree within one year of service separation, or were otherwise casually related to his active service or any incident therein. Moreover, although the record contains some indication that the appellant may have been treated for an episode of malaria in 1942, possibly during active service, the medical evidence establishes that malaria did not cause his death. Rather, in this appeal, the appellant asserts that the Veteran had malaria during service, had a relapse of malaria shortly before his death, and that such malaria relapse aggravated his pneumonia, one of the contributing causes of his death, or alternatively rendered him materially less capable of resisting the effects of pneumonia. After carefully considering the appellant's contentions in light of the record on appeal, the Board finds that the preponderance of the evidence is against the claim. As set forth above, the record contains a February 1980 opinion from one Dr. C. who indicated that he had treated the Veteran in April 1978, for various symptoms, including a productive cough and fever. Dr. C. indicated that his clinical diagnoses were chronic malaria and pneumonia. He noted that "this malaria may cause serious infection with localization of the causative agent (pneumonic type)." As delineated in detail above, however, the record also contains multiple medical opinions which weigh against the claim. Again, these medical opinions indicate that it is less likely than not that the appellant had malaria at the time of his death, or that any presumed malaria relapse in 1978 caused or aggravated the Veteran's fatal pneumonia, or that any presumed malaria relapse in 1978 rendered the Veteran materially less capable of resisting the effects of the fatal pneumonia. After carefully considering the appellant's contentions in light of the record on appeal, the Board finds that the preponderance of the evidence is against the claim. In that regard, the Board finds that the VA medical opinions in this case are persuasive and assigns them great probative weight. The opinions were rendered by a medical professional with the expertise necessary to opine on the question at issue in this case, i.e. a physician who specializes in pulmonary medicine. In addition, the physician reviewed the record on appeal and expressly considered the appellant's contentions, factors which further increase the weight of his opinion. The examiner specifically addressed the Veteran's medical history, referenced pertinent information in the record such as laboratory findings and the autopsy findings, and provided a very detailed and thorough rationale for his conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). The opinon from Dr. C., on the other hand, contains no rationale nor is it supported by laboratory findings establishing the basis for the diagnosis of malaria. In any event, Dr. C's suggestion that malaria may cause or aggravate pneumonia is framed in speculative terms. It is well established that medical opinions that are inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible" and "it is within the realm of medical possibility" too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the words "could not rule out" was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that a physician's statement that a service-connected disorder "may or may not" have prevented medical personnel from averting a Veteran's death was not sufficient). Given the applicable standard of proof, the Board finds that Dr. C.'s statement is insufficient to support an award of service connection and certainly does not equal or outweigh the extremely probative VA medical opinion evidence discussed above. In summary, the Board finds that the probative evidence establishes that the cause of the Veteran's death, metastatic carcinoma involving the liver, lungs, and lymph nodes with pneumonia, was not causally related to his active service or any incident therein, including an episode of malaria or a claimed recurrence of malaria in 1978, nor was either condition causally related to or aggravated by malaria, nor did malaria render him materially less capable of resisting the effects of pneumonia. Rather, the Board finds that the overwhelming preponderance of the evidence shows that the Veteran died from complications of metastatic cancer, including pneumonia. His cancer was first shown decades after service and there is no probative evidence that suggests a nexus between his cancer and his active service. Service connection was not in effect for any disease or disability during the Veteran's lifetime. As to the alleged role of malaria in the Veteran's death, although there is some evidence suggesting a possible isolated episode in 1942, possibly during service, and an another possible episode in 1978, approximately 4 months prior to the Veteran's death, there are no laboratory findings to support the 1978 diagnosis of malaria and autopsy findings indicate chronic malaria was not present at death. More importantly, VA has obtained multiple medical opinions regarding the claim that malaria caused or aggravated the Veteran's fatal pneumonia and such opinions consistently and clearly indicate that there is no basis upon which to conclude that malaria either caused or aggravated the Veteran's pneumonia or that it rendered him materially less capable of withstanding the effects of the fatal pneumonia. Rather, the Veteran's autopsy findings were not consistent with a recent episode of malaria and rule out any role whatsoever in the Veteran's death. Under these circumstances, the Board concludes that service connection for the cause of the Veteran's death is not warranted. The Board considered the doctrine of reasonable doubt but as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 7 Vet. App. 49 (1990). ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ______________________________________________ Cheryl L. Mason Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs