Citation Nr: 1518640 Decision Date: 04/30/15 Archive Date: 05/05/15 DOCKET NO. 12-16 551A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for neuropathy of the bilateral upper extremities, to include as due to herbicide exposure. 2. Entitlement to service connection for neuropathy of the bilateral lower extremities, to include as due to herbicide exposure. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial compensable rating for bilateral hearing loss. 5. Entitlement to service connection for rectal carcinoma, to include as due to herbicide exposure. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). 7. Entitlement to recognition of the Veteran's son, O.L.H., as a "helpless child" on the basis of permanent incapacity for self-support prior to attaining the age of eighteen. REPRESENTATION Appellant represented by: Southeast Texas Soldiers Advocates WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1961 to October 1967. This matter comes on appeal before the Board of Veterans' Appeals (Board) from the March 2012 and September 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. This appeal was processed using the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In evaluating this case, the Board has also reviewed the "Virtual VA" system to ensure a complete assessment of the evidence. The Veteran testified before the undersigned in a December 2014 video conference Board hearing, the transcript of which is included in VBMS. The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU due to service-connected disability is part and parcel of an increased rating claim when such claim is raised by the record. Entitlement to a TDIU was denied in a December 2014 rating decision; however, in the subsequent December 2014 Board hearing, the Veteran stated that he was unable to work as a result of his rectal carcinoma disorder (currently on appeal). Therefore, the issue of entitlement to TDIU has once again been raised during the course of the appeal. In light of the Court's holding in Rice, the Board has considered the TDIU claim as part of his pending claims, and is listing the raised TDIU claim as an issue on appeal. The issues of (1) an initial rating in excess of 30 percent for PTSD; (2) an initial compensable rating for bilateral hearing loss; (3) service connection for rectal carcinoma, to include as due to herbicide exposure; (4) entitlement to a TDIU; and (5) recognition of the Veteran's son, O.L.H., as a "helpless child" on the basis of permanent incapacity for self-support prior to attaining the age of eighteen are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has currently diagnosed bilateral upper and lower alcoholic neuropathy. 2. Currently diagnosed alcoholic neuropathy was not incurred in service and is not etiologically related to service, to include herbicide exposure. 3. The Veteran's diagnosed alcoholic neuropathy is not caused or aggravated by the service-connected PTSD disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral upper extremity neuropathy are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2014). 2. The criteria for service connection for bilateral lower extremity neuropathy are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her 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 a May 2012 notice letter, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits, and described the types of information and evidence that the Veteran needed to submit to substantiate the claim. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claim. The RO further informed the Veteran how VA determined the disability rating and effective date once service connection is established. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied. Regarding VA's duty to assist in claims development, the Veteran's service treatment records, post-service treatment records, the December 2014 hearing transcript, and the Veteran's statements are of record. Therefore, the Board concludes VA's duty to assist in obtaining records has been satisfied. 38 C.F.R. § 3.159(c). The Veteran has not been provided with a VA examination or medical opinion for the current upper and lower extremity neuropathy claims. In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006) In this case, because the weight of the evidence is against finding any injuries, diseases, or events in service that could serve as a basis for service connection for neuropathy, there is no duty to provide a VA medical examination. Absent evidence at least suggestive of an in-service event, injury, or disease to which a competent medical opinion could relate the claimed disability, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the claims for service connection for neuropathy of the upper and lower extremities without being speculative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based on an inaccurate factual premise is not probative). In written and oral testimony, the Veteran has made the specific contention that his neuropathy of the upper and lower extremities is related to herbicide exposure; however, as discussed in more detail below, service connection based on exposure to herbicides is determined by actual or presumed exposure to herbicides, and not a medical opinion. As the Veteran has made no assertions or submitted any evidence contending onset of symptoms or actual diagnosis of neuropathy in service, the Board finds that VA's duty to assist the Veteran in obtaining additional evidence to support a nexus has not been triggered. See 38 U.S.C.A. § 5103A(a)(2) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"); Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that, where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). For these reasons, the Board finds that a remand for an additional medical opinion is not warranted. Given the foregoing, the Board finds 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; therefore, the Board will proceed with review. Service Connection Laws and Regulations 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). The condition of neuropathy (organic disease of the nervous system) is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provision of 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, 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). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Neuropathy The Veteran contended that his neuropathy of his bilateral lower and upper extremities is related to his exposure to Agent Orange while stationed in Vietnam. See Veteran's October 2011 statement. A Veteran who, during active service, served in the Republic of Vietnam during the Vietnam era (beginning in January 1962 and ending in May 1975) shall be presumed to have been exposed during such service to certain herbicide agents, including an herbicide commonly referred to as Agent Orange. 38 U.S.C.A. § 1116(f); 38 C.F.R. §§ 3.307, 3.309. If a Veteran was exposed to a herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II or adult-onset diabetes mellitus), Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2014). VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically determined that a presumption of service connection is warranted. Notice, 79 Fed. Reg. 20,308 (2014). Pursuant to 38 C.F.R. § 3.309(e), early-onset peripheral neuropathy must manifest to a degree of 10 percent or more within one year after the last date on which the Veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.307(a)(6)(ii) (2014). A recent amendment to the regulation replaced the term "acute and subacute peripheral neuropathy" with the term "early-onset peripheral neuropathy." VA also removed a note with the requirement that the neuropathy be transient and appear within weeks or months of exposure to an herbicide agent and resolve within two years of the date of onset. Disease Associated With Exposure to Certain Herbicide Agents: Peripheral Neuropathy, 78 Fed. Reg. 54763-54766 (Sept. 6, 2013). It was further noted that the amendment clarified that VA will not deny presumptive service connection for early-onset peripheral neuropathy solely because the condition persisted for more than two years after the date of the last herbicide exposure. However, it does not change the requirement that peripheral neuropathy must have become manifest to a degree of 10 percent or more within one year after a Veteran's last in-service exposure in order to qualify for the presumption of service connection. A September 29, 2010, National Academy of Sciences report, Veterans and Agent Orange: Update 2010, was noted to have found that evidence did not support an association between herbicide exposure and delayed-onset peripheral neuropathy, which was defined as having its onset more than one year after exposure. The Board initially finds that "alcoholic neuropathy" is not included in the list of presumptive diseases. A presumption of service connection based on exposure to herbicides is not warranted for any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See 68 Federal Register 27630-27641 (May 20, 2003). Nonetheless, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F. 3d 1039, 1042 (Fed. Cir. 1994). 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 noted above, the Veteran served on active duty from July 1961 to October 1967. This includes service in Vietnam; as such, his exposure to Agent Orange is conceded. See 38 C.F.R. §§ 3.307, 3.309. Service treatment records do not contain any complaints, history, treatment, or diagnosis of a neurological condition, to include neuropathy of the extremities. Further, the September 1967 service separation examination report reveals that the Veteran had a normal neurological clinical evaluation at service discharge. There were also no disorders or diagnoses noted regarding the Veteran's upper and lower extremities. Post-service treatment records reveal that that the first indication of neuropathic pain was in 2011. See April 2011 VA treatment record. He was later diagnosed with alcoholic neuropathy in 2012, more than 40 years after service separation. See March 2012 VA Mental Health Outpatient Visit Note. Upon review of the evidence of record, the Board finds that the record does not contain a diagnosis of early-onset peripheral neuropathy. In this regard, the regulations require that peripheral neuropathy must have become manifest to a degree of 10 percent or more within one year after a Veteran's last in-service exposure in order to qualify for the presumption of service connection. As there is no evidence that the peripheral neuropathy manifested within a year after the Veteran left Vietnam, the presumption of 38 C.F.R. § 3.309 (e), does not apply. The Board acknowledges that the Veteran need not prove that the association between peripheral neuropathy and herbicide exposure was known when he separated from service. He must establish, however, that his peripheral neuropathy manifested to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection. As noted, the record does not establish these facts. In sum, the evidence demonstrates that there was no diagnosis of a neurological condition in service treatment records. There was also no continuity of symptoms after service in private or VA medical records, or by the Veteran's own statements and testimony during the December 2014 Board hearing. Additionally, the first mention of symptoms was approximately 40 years after service. The diagnosis of the Veteran's neurological condition, i.e., alcoholic neuropathy, did not occur until 2012. Therefore, the Veteran's neurological disability did not manifest within one year separation from service. Accordingly, service connection for neuropathy is not warranted on a presumptive basis of chronicity or continuation of symptoms. While the Veteran is not entitled to a regulatory presumption of service connection, either on the basis of chronicity or herbicide exposure, the Board will also review his claim to determine if service connection can be established for his alcoholic neuropathy on a direct basis. See Combee, supra. The Veteran asserts he has neuropathy and that it resulted from his service in Vietnam. As a lay person, the Veteran is competent to describe symptoms, which he is able to perceive through the use of his senses. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses). Further, the Veteran's statements and testimony are admissible and are to be considered as evidence of continuity. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept in determining whether lay evidence may be considered, in other words, whether the evidence is admissible). The Board thus finds that the Veteran is competent to describe his symptoms in service and thereafter. Although the Veteran is competent to describe symptoms of neuropathy such as numbness and tingling in his extremities, he does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of his neuropathy. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Neuropathy is a medically complex disease process because of its multiple possible etiologies, requires specialized testing to diagnose, and manifests symptomatology that may overlap with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). As noted, the Veteran does not assert, nor does the medical evidence establish the onset of neuropathy symptoms until 2011, when he reports neuropathic pain during treatment at a VA medical facility. In the absence of demonstration of continuity of symptomatology, or a competent nexus opinion, the initial demonstration of current disability years after service is too remote from service to be reasonably related to service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (the Federal Circuit has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim). Here, the lapse of time from separation in October 1967 to the first notation of complaints or treatment of neurological symptoms of any extremity weighs against the claim. The Board has also considered the medical evidence of record. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The only competent medical evidence as to the etiology of the Veteran's neurological disability are VA treatment records which have associated the Veteran's neuropathy with alcohol intake. See VA treatment records dated January 2012, February 2012, March 2012, April 2012, April 2013, and November 2013. Notably, these VA treatment records do not relate the Veteran's neuropathy to service, to include herbicide exposure. Further, the Veteran is service-connected for PTSD. In an October 2011 VA PTSD examination report, it was noted that the Veteran was first presented for psychiatric services in 2011 when he presented to the emergency room for symptoms of alcohol withdrawal. The examiner then opined that the Veteran's currently diagnosed PTSD was directly related to service; however, the examiner opined that his previous significant alcohol use, was not secondary to his PTSD disability as it was a "behavioral choice." Although VA treatment records suggest that the Veteran's bilateral upper and lower extremity neuropathy is due to the Veteran's significant alcohol use, the Veteran's alcohol use has not been related to service or to his service-connected PTSD disability. See Allen, 7 Vet. App. at 448. As such, the Board finds that service connection for neuropathy of the upper and lower extremities as secondary to the service-connected PTSD disability is not warranted. For these reasons, the Board finds that the weight of the medical evidence is against an association or link between the neurological disability of the upper and lower extremities and service or to a service-connected disability. The preponderance of the evidence is against the claims for service connection for upper and lower neuropathy on the applicable theories of service connection discussed above, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Service connection for neuropathy of the bilateral upper extremities, to include as due to herbicide exposure, is denied. Service connection for neuropathy of the bilateral lower extremities, to include as due to herbicide exposure, is denied. REMAND PTSD and Bilateral Hearing Loss Disabilities In regard to the claims for an initial rating in excess of 30 percent for PTSD and an initial compensable rating for bilateral hearing loss, additional evidence was added to the claims file in September 2014. See August 2014 DBQ psychiatric and audio examination reports. This relevant medical evidence was received, and is dated after, the most recent supplemental statement of the case, issued in March 2014. Generally, the submission of new evidence without a waiver of consideration by the agency of original jurisdiction warrants a remand for such consideration of this evidence. See 38 C.F.R. § 20.1304 (2014). A review of the electronic claims file, to include the December 2014 Board hearing transcript, does not contain a waiver of AOJ consideration of this new evidence. Accordingly, the claims for an initial rating in excess of 30 percent for PTSD and an initial compensable rating for bilateral hearing are remanded to the AOJ for review and re-adjudication. TDIU As discussed above, a TDIU claim is part of this appeal pursuant to Rice, 22 Vet. App. 447. As any decision with respect to the claims for an increased rating for PTSD and hearing loss may affect the claim for a TDIU, the claim for a TDIU is inextricably intertwined with the claims for an increased rating on appeal; as such, adjudication of the TDIU claim is deferred until adjudication of the increased rating claims. Rectal Carcinoma The Veteran maintains that he developed this disorder as a result of exposure to Agent Orange while in service. The Veteran had a period of service in the Republic of Vietnam during the Vietnam Era, and therefore his exposure to Agent Orange is presumed. The Veteran has also been diagnosed with stage II rectal cancer and has undergone a colostomy, but does not have a diagnosed disorder that is recognized under 38 C.F.R. § 3.309(e) as a disease for which presumptive service connection is available on the basis of herbicide exposure. Nonetheless, the Veteran may establish service connection based on exposure to Agent Orange with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has not been afforded a VA examination regarding the etiology of his rectal cancer disorder. He maintains that rectal sarcoma is a form of "soft tissue sarcoma" and thus should be service-connected on a presumptive basis. See October 2012 notice of disagreement. The Board recognizes that certain soft tissue sarcomas are presumed to be service-connected for veterans who were exposed to Agent Orange. See 38 C.F.R. § 3.309(a). Note 1 in this section indicates that the term "soft-tissue sarcoma" includes the following: adult fibrosarcoma; dermatofibrosarcoma protuberans; malignant fibrous histiocytoma; liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; clear cell sarcoma of tendons and aponeuroses; extraskeletal Ewing's sarcoma; congenital and infantile fibrosarcoma; and malignant ganglioneuroma. See 38 C.F.R. § 3.309(e). The Veteran essentially contends that because Note 1 does not expressly state that it is an exclusive list of the cancers known as soft tissue sarcomas, there may be other eligible soft tissue sarcomas, such as rectal carcinoma. To support this theory, the Veteran stated that he had reviewed "cancer research studies." See Veteran's October 2012 notice of disagreement. Accordingly, the Board finds that the Veteran should be afforded a VA examination to assist in determining whether his currently diagnosed rectal carcinoma is related to service, to include herbicide exposure. Helpless Child Claim The Veteran is seeking additional dependent benefits for his adult son, O.L.H., on the basis that he is a helpless child permanently incapable of self-support. He was born in 1975 and turned 18 years old in 1993. The Board's review of the record reveals that further development of this issue is required. In an October 2011 statement, the Veteran's wife noted that their son was in receipt of Supplemental Security Income benefits through the Social Security Administration (SSA). To ensure that the record is complete, the RO/AMC should obtain records associated with O.L.H.'s award of Supplemental Security Income by the SSA as such records are relevant to the current appeal and must be obtained. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010); see also 38 C.F.R. § 3.159(c)(2). Further, O.L.H.'s mother has reported, and has submitted supporting evidence, that O.L.H. received treatment from Dr. Williams. According to a June 2012 letter, Dr. Williams had dictated a letter in support of the claim, but due to his busy schedule, had not been able to submit the letter to VA. The June 2012 letter notes that the Veteran's son had psychological and medical problems at a very young age and was enrolled in special education classes. A review of the evidence of record reveals that treatment records pertaining to O.L.H. have not been requested. On remand, efforts should be made to obtain these treatment records and associate them with the claims file. Further, the Board finds that a VA examination of the Veteran's son may aid in substantiating the claim. Thus, the Board finds that a VA examination of the Veteran's son is warranted. Accordingly, the case is REMANDED for the following actions: 1. Request from the SSA all medical records upon which O.L.H.'s claim or award of SSI was based. All records obtained or any response received should be associated with the claims folder. If the RO/AMC cannot locate any Federal records requested herein, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must notify the claimant of the specific records that it is unable to obtain, explain the efforts VA has made to obtain that evidence, and describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. 2. Ascertain if the Veteran's son, O.L.H., has received any pertinent medical treatment, to include treatment records from Dr. Williams. Provide the Veteran with the necessary authorizations for the release of any private treatment records not currently on file. Obtain any identified treatment records and associate them with the claims folder. If unsuccessful in obtaining any medical records identified by the Veteran, inform him of this fact and provide her an opportunity to submit copies of the outstanding medical records. 3. After completing the above requested development, schedule the Veteran's son, O.L.H., for a VA examination at an appropriate location. If the Veteran's son is not available for an examination, detail the reasons for unavailability and direct the examiner to a comprehensive claims file review to respond to the inquiries below. Furnish the entire record to the examiner for review. The examiner is requested to provide a medical opinion as to whether it is at least as likely as not (50 percent or greater probability) that O.L.H. was permanently incapable of self-support at the time of his 18th birthday. The examiner should state (if possible) what employment limitations would have existed at age 18 and what limitations are currently shown. If O.H.L. was incapable of self-support as of his 18th birthday, then determine whether it is at least as likely as not that incapability of self-support continued after his 18th birthday. The examination report must include discussion of the son's treatment history and diagnoses of all significant disabilities. All indicated tests and studies must be accomplished and all clinical findings must be reported in detail. A complete rationale must be provided for any opinion given. If the examiner cannot provide opinion without resort to speculation, the examiner is requested to explain why an opinion would be speculative. 4. Obtain the Veteran's up-to-date VA treatment records and associate them with the electronic claims file. 5. Then, scheduled the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's rectal carcinoma. Based on examination findings, including any necessary diagnostic studies, as well as a review of the claims file, including treatment records, the Veteran's statements, and a copy of this REMAND, the examiner is requested to answer the following: (a) Is the Veteran's rectal cancer is a "soft tissue sarcoma" pursuant to Note 1 under 38 C.F.R. § 3.309 (2014) (see list of soft tissue sarcomas in remand section above). (b) If the answer to (a) is negative, is it at least as likely as not (i.e. a probability of 50 percent or greater) that the Veteran's rectal cancer had its onset during active service; was related to the Veteran's presumed in-service herbicide exposure; or otherwise related to active service. Assume the Veteran was exposed to herbicides (Agent Orange). The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. A complete rationale must be provided for any opinion given. If the examiner cannot provide opinion without resort to speculation, the examiner is requested to explain why an opinion would be speculative. 6. After undertaking any other additional development deemed necessary, re-adjudicate the claims on appeal based on all the evidence of record. If any benefits sought on appeal remain denied, the Veteran and his representative should be furnished with a supplemental statement of the case, and should be afforded the applicable 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 2014). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs