Citation Nr: 1523076 Decision Date: 06/02/15 Archive Date: 06/16/15 DOCKET NO. 12-12 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for recurrent right carpal tunnel syndrome, status post right open carpal tunnel release. 2. Entitlement to service connection for a respiratory disorder, to include asbestosis and chronic obstructive pulmonary disorder (COPD). REPRESENTATION Veteran represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from March 1965 to March 1968. This appeal comes to the Board of Veterans' Appeals (Board) from a July 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which, in pertinent part, denied service connection for a right hand disorder and asbestosis. A claim for service connection right carpal tunnel syndrome and asbestosis was received by VA in December 2009. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. The Veteran initially claimed entitlement to service connection for asbestosis. Pursuant to Clemons, the Board finds that the issue of entitlement to service connection for all respiratory disorders is in appellate status. The Board has recharaterized the issues on the title page of this decision to reflect this finding. In March 2015, the Veteran testified at a Board videoconference hearing at the local RO in Muskogee, Oklahoma, before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of the hearing is of record. The issues of (1) increased disability ratings for the service-connected left shoulder status post impingement release, status post myocardial infarction, posttraumatic stress disorder (PTSD), and bilateral hearing loss, and (2) service connection for left arm nerve damage (to include as secondary to the service-connected left shoulder disability) and a back disorder have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). See application for disability compensation and related compensation benefits (VA Form 21-526EZ). Therefore, the Board does not have jurisdiction over these claims, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2014). FINDINGS OF FACT 1. Symptoms of right carpal tunnel syndrome have been continuous since service. 2. The Veteran was exposed to asbestos during service. 3. The Veteran does not have, nor has he had at any time proximate to or during the course of this appeal, asbestosis. 4. The Veteran's current diagnosed COPD manifested many years after service separation and is not causally or etiologically related to active military service, to include in-service exposure to asbestos. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for recurrent right carpal tunnel syndrome, status post right open carpal tunnel release, have been met. 38 U.S.C.A. §§ 1110, 1112, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2014). 2. A respiratory disorder, to include asbestosis and COPD, was not incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 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 a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159 (2014). 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, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2014). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board is granting service connection for right carpal tunnel syndrome, constituting a full grant of the benefit sought on appeal with respect to this issue. As there remains no aspect of the claim to be further substantiated, there is no further VCAA duty to notify or assist, or to explain compliance with VCAA duties to notify and assist with respect to this issue. With respect to the issue of service connection for a respiratory disorder, in this case, the RO provided notice to the Veteran in January 2010, prior to the initial adjudication of the claim in July 2010. The Veteran was notified of the evidence not of record that was necessary to substantiate the claim, VA and the Veteran's respective duties for obtaining evidence, and how disability ratings and effective dates are assigned; thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Specifically, the information and evidence that have been associated with the claims file include service treatment records, service personnel records, VA treatment records, private treatment records, a copy of the March 2015 Board hearing transcript, and lay statements. At the March 2015 Board hearing, the Veteran's representative contended that the Veteran never received an "asbestos exposure questionnaire" from the RO. As discussed below, the Board finds that the Veteran was in fact exposed to asbestos during service; therefore, as the factual question for which the questionnaire is designed to elicit evidence has been proven, the purpose of the questionnaire has been rendered moot, the Veteran is not prejudiced by not receiving the claimed questionnaire. The Veteran also testified that he did not receive a physical examination when he separated from active service in March 1968; however, review of the service treatment records reveals that a service separation physical examination was conducted in March 1968. The Veteran also completed a report of medical history in connection with the March 1968 service separation physical examination. The March 1968 service separation physical examination report and associated report of medical history have been associated with the claims file. As such, the Board finds that VA has made every reasonable effort to obtain all records relevant to the Veteran's claims. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Indeed, even when the adequacy is challenged, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). With respect to the claim for service connection for a respiratory disorder, the Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in July 2011 and July 2014. At the March 2015 Board hearing, the Veteran testified that he "didn't think [the July 2011 VA examination] was much of an examination" because "they just had a little hand-held meter and had [him] blow in it" and then performed X-rays. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that a claimant challenging the expertise of a VA physician must "set forth the specific reasons . . . that the expert is not qualified to give an opinion." Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010). Specific reasons alleging inadequacy of the examinations has not been proffered in this case. While the Veteran has expressed disagreement with how the VA examination was conducted, the Veteran, as a lay person, has not been shown to have the requisite medical knowledge, training, or experience to diagnosis asbestosis so as to call into question the clinical diagnoses that are of record. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). The Board finds that the VA examiner was competent and qualified through education, training, and experience to perform an adequate VA examination and offer medical diagnoses, statements, and opinions. See Cox, 20 Vet. App. 563. The Board finds the July 2011 and July 2014 VA examination reports were thorough and adequate and provide a sound basis upon which to base a decision with regard to this issue. The VA examiners personally interviewed and examined the Veteran, including eliciting a history, diagnosed current respiratory disorders, and provided opinions with supporting rationale. The Veteran testified at a March 2015 Board hearing before the undersigned Veterans Law Judge and a transcript is of record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above 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. In this case, during the Board hearing, the Veterans Law Judge advised the Veteran as to the issues on appeal, what was generally required for service connection, and suggested the importance of getting a medical nexus opinion relating asbestos exposure to any current respiratory disabilities. The Veteran presented evidence of symptoms of the claimed asbestosis and testified as to in-service events and exposure to asbestos. Further, the Veteran was provided VA examinations in July 2011 and July 2014 that provide additional evidence on the question of whether the Veteran has a current diagnosis of asbestosis and the etiology of any currently diagnosed respiratory disorders. Moreover, neither the Veteran nor the representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) and have not identified any prejudice in the conduct of the Veterans Law Judge. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection Laws and Regulations Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a) (2014). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In this case, the Veteran has been diagnosed with right carpal tunnel syndrome, which may be considered an organic disease of the nervous system and is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for "chronic" in service symptoms and "continuous" post-service symptoms apply with respect to this claim. The Veteran has claimed service connection for asbestosis. As discussed below, the Board finds that the weight of the evidence is against a finding that the Veteran has current asbestosis; therefore, it cannot be a "chronic disease" under 38 C.F.R. § 3.309(a). Further, the Veteran's currently diagnosed COPD is not a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) do not apply to the claim for service connection for a respiratory disorder. For a chronic disease such as carpal tunnel syndrome, service connection may be established under 38 C.F.R. § 3.303(b) if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Continuity of symptomatology after service is required where a condition noted during service is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). The presumptive service connection provisions based on "chronic" in-service symptoms and "continuity of symptomatology" after service under 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). Service connection may also be established with certain chronic diseases, including organic diseases of the nervous system, based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from 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 2014); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumptive 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. Service Connection for Right Carpal Tunnel Syndrome The Veteran filed a claim for service connection for right carpal tunnel syndrome in December 2009. The Veteran essentially contends that the right carpal tunnel syndrome onset during, and has continued since, active service. See March 2015 Board hearing transcript. In an April 2012 substantive appeal (on a VA Form 9), the Veteran contended that being right hand dominant and using hand tools on a daily basis as a heavy equipment mechanic during service caused the right carpal tunnel syndrome. At the March 2015 Board hearing, the Veteran contended that the carpal tunnel syndrome started in service, has continued since service separation, and still affects him today. The Veteran testified that the numbness and tingling in his right hand began in service and that he continued to experience symptoms of pain, swelling, and numbness in the right hand since service separation. First, the evidence of record demonstrates that the Veteran now has recurrent right carpal tunnel syndrome, status post right open carpal tunnel release. See April 2012 VA treatment record. Next, the Board finds that the Veteran experienced an in-service right hand injury. A February 1966 service treatment record notes that the Veteran reported injuring his right hand the previous night. An injury and eight erosions were noted on the right hand and the wound was cleaned and dressed. In the December 2012 claim, the Veteran reported injuring his right hand when a large u-joint fell on his hand. The Veteran reported injuring his right hand on more than one occasion while performing work as a mechanic during service. The Board further finds that the evidence is at least in equipoise on the question of whether symptoms of the Veteran's right carpal tunnel syndrome have been continuous since service. Although the Veteran was not specifically diagnosed with right carpal tunnel syndrome in active service, such is not required. See 38 C.F.R. § 3.303(d) (providing service connection may be granted for any disease diagnosed after service when the evidence establishes in-service incurrence). The evidence of record demonstrates an in-service right hand injury and the Veteran has reported numbness and tingling in the right hand during service that continued to worsen since separation. See March 2015 Board hearing transcript. January to May 2001 private treatment records note that the Veteran reported right hand numbness and paresthesias. A February 2001 private treatment record notes that the Veteran reported paresthesia of the right hand for some time that had been unresponsive to brace treatment. The Veteran underwent a carpal tunnel release of the right hand. An April 2012 VA treatment record notes that the Veteran reported numbness in the hands for years that had progressively worsened. The Veteran reported a history of a right carpal tunnel release in the 1970s. Throughout the course of this appeal, the Veteran has consistently contended that symptoms of right carpal tunnel syndrome, including numbness and tingling in the fingers, began during service and continued to worsen since service separation. The Board finds that the Veteran has provided credible statements and testimony as well as accurate lay histories provided to medical personnel that his right carpal tunnel syndrome has been continuous since service. Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay statements regarding continuity of symptomatology provide a direct link between the active service and the current state of his condition). Resolving reasonable doubt in the Veteran's favor, the Board finds that symptoms of right carpal tunnel syndrome were continuous since service separation. The Board finds that the Veteran's reports of right carpal tunnel syndrome since service separation, in the context of the demonstrated in-service right hand injury and current diagnoses, are sufficient to place in equipoise the question of whether the current right carpal tunnel syndrome was incurred in service. Additionally, post-service treatment records demonstrate that the Veteran's right carpal tunnel syndrome continued to worsen after service separation. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that, based on continuous post-service symptoms, presumptive service connection for right carpal tunnel syndrome is warranted for continuous post-service symptoms of chronic disease under 38 C.F.R. § 3.303(b). 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The grant of presumptive service connection renders moot all other theories of service connection, including the need for direct nexus opinions rendered in the July 2011 and July 2014 VA examination reports. Service Connection for a Respiratory Disorder The Veteran filed a claim for service connection for asbestosis in December 2009. The contention liberally construed for the Veteran is that his claimed asbestosis is related to active service, specifically exposure to asbestos while working as a track vehicle mechanic during service. See December 2009 claim, April 2012 substantive appeal. The Veteran contends that he maintained and repaired brakes that were covered with asbestos. The Veteran further contends that the work areas and living quarters during service all had asbestos materials. See March 2015 Board hearing transcript. The Veteran denied working on heavy equipment that involved asbestos after service. First, the Board finds that the weight of the evidence is against a finding that the Veteran has current asbestosis. In an August 2008 letter, Dr. C.J. noted that a July 2008 chest x-ray reflected parenchymal changes diagnostic of pneumoconiosis. Dr. C.J. opined that, given the Veteran's history of asbestos exposure (the Veteran reported a work history of asbestos exposure) and the appropriate latency period, the parenchymal changes were, within a reasonable degree of medical certainty, diagnostic of a history of asbestos exposure and underlying asbestosis. In a September 2008 letter, Dr. D.S. noted that the Veteran was referred for evaluation of possible pneumoconiosis. The Veteran reported that, while working as a welder and fitter for almost his entire career, he worked with equipment that was insulated with asbestos and worked around others who were using and removing asbestos-containing material. Dr. D.S., based on the Veteran's medical history, occupational exposure, physical examination, chest x-rays, and pulmonary function tests, opined that, within a reasonable degree of medical probability, the Veteran had asbestos and emphysema. At the July 2011 VA examination, the VA examiner, after physical examination, chest x-ray, and review of the claims file, including the August and September 2008 private medical opinions, opined that there was no pathology to render a diagnosis of asbestosis. The July 2014 VA examination report notes that a B-reader interpretation (an approval granted to physicians who demonstrate proficiency in the classification of chest radiographs for pneumoconioses) of the chest x-rays reflected no radiographic findings to establish a diagnosis of occupational pneumoconiosis or pulmonary asbestosis. The Board finds that the July 2011 and July 2014 VA examination findings of no current asbestosis disability outweigh the August and September 2008 private medical opinions. While both Dr. D.S. and Dr. C.J. quantified their opinions that the Veteran had asbestosis within a reasonable degree of medical certainty or probability, the July 2011 and July 2014 VA examiners gave unequivocal opinions that the Veteran does not have current diagnosed asbestosis. The VA examiners reviewed the claims file, including the August and September 2008 private medical opinions indicating that the Veteran had asbestosis within a reasonable degree of medical certainty, and reviewed contemporaneous chest radiographic reports, in coming to their conclusions that the Veteran does not have a current diagnosis of asbestosis. Owens v. Brown, 7 Vet. App. 429, 433 (1995) (VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators . . ."). The Veteran has consistently contended, throughout the course of this appeal and in statements to health care providers, that he has asbestosis. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr, 21 Vet. App. at 308-09. Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). While, as a lay person, the Veteran is competent to relate some respiratory symptoms that may be associated with the claimed asbestosis, the Board finds that in the particular case the Veteran does not have the requisite medical knowledge, training, or experience to be able to diagnose the medical complex disability of asbestosis. Asbestosis is a medically complex disease process because of its multiple etiologies, requires specialized testing to diagnose, and manifests in observable symptomatology that overlaps with other disorders, including COPD, with which the Veteran is currently diagnosed. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis); Kahana, 24 Vet. App. at 437 (recognizing ACL injury is a medically complex disorder that requires a medical opinion to diagnose and to relate to service or differentiate from in-service symptoms and diagnosis). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that service connection can also be warranted if there was a disability present at any point during the claim period, even if it is not currently present); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that a current disability may include a diagnosis at the time the claim was filed or during its pendency). While two diagnose of asbestosis were rendered in August and September 2008, the Board finds that the weight of the evidence in this case is against finding asbestosis at any point during the claim period or even recent diagnoses prior to the filing of the claim for service connection. See Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010) (stating that there must be "medically competent" evidence of a current disability) (emphasis added). The VA examiners' opinions have provided strong rationale as to why the Veteran's reported symptoms do not warrant a diagnosis of asbestosis. The evidence of record demonstrates that the Veteran has current diagnosed COPD. See July 2014 VA examination report. The Board finds that the Veteran was exposed to asbestos during service. The evidence of record includes the Veteran's DD Form 214 that notes a military occupational specialty of track vehicle mechanic. At the March 2015 Board hearing, the Veteran reported that he was exposed to asbestos on a regular basis while working and repairing brakes that were covered with asbestos. The Board finds that the Veteran's contentions concerning asbestos exposure in service are consistent with his occupational specialty and the places, types, and circumstances of his service. 38 U.S.C.A. § 1154(a) (West 2014). After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the currently diagnosed COPD is not related to active service, including to the asbestos exposure during service. While the Veteran was exposed to asbestos during service, in-service asbestos exposure does not mandate that service connection be granted; rather, the in-service asbestos exposure must be shown to have at least as likely as not caused the current COPD. The March 1968 service separation physical examination report notes that the Veterans lungs and chest were clinically normal. On an associated report of medical history, the Veteran denied asthma, shortness of breath, pain or pressure in the chest, and chronic cough. At the July 2011 VA examination, the Veteran reported that his respiratory disorder had existed for three years. At the July 2014 VA examination, the Veteran reported being diagnosed with COPD in 2000. The VA examiner opined that the Veteran's COPD was less likely than not incurred in or caused by service, including in-service asbestos exposure, because COPD is not caused by asbestos exposure. The July 2014 VA examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. The VA examiner had the requisite medical expertise to render a medical opinion regarding the etiology of the Veteran's COPD and had sufficient facts and data on which to base conclusions. The Board finds the July 2014 VA examination report to be highly probative. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr at 308-09. Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert, 21 Vet. App. at 462 (concerning rheumatic fever); Jandreau, at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); see 38 C.F.R. § 3.159(a)(2). The Veteran has not contended that the COPD is directly related to active service. Rather, as discussed in detail above, the Veteran has consistently contended that he has asbestosis that was caused by in-service asbestos exposure. To the extent that the Veteran's claim may be interpreted to encompass the current diagnosed COPD, the etiology of the Veteran's current COPD is a complex medical etiological question involving internal and mostly unseen system processes unobservable by the Veteran that manifest in some general symptoms of breathing disorder that are common to many respiratory disorders. The question of causation of COPD involves knowledge of multiple other causes of COPD so as to eliminate other etiologies. The Board does not find the Veteran competent to provide evidence of an etiological nexus between the in-service asbestos exposure and COPD that developed after service separation, especially in this case where there is no diagnosis or treatment for symptoms for many years after service. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran does not have asbestosis and the current diagnosed COPD was not incurred in or otherwise caused by active service, to include in- service asbestos exposure. As the preponderance of the evidence is against the claim for service connection for a respiratory disorder, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for recurrent right carpal tunnel syndrome, status post right open carpal tunnel release, is granted. Service connection for a respiratory disorder, to include asbestosis and COPD, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs